Lived Experiences of Food Insecurity among Adults Who Have Ever Smoked Tobacco

Abstract

Food insecurity and smoking are bidirectionally related due to factors such as poverty, stress, and hunger. This qualitative study examined the lived experiences of food insecurity among low-income individuals who have ever smoked, to understand the burden of food insecurity in relation to current smoking status. Participants were recruited from community-based settings and reflexive thematic analysis was used to identify key themes. Participants experienced complex challenges and employed various coping strategies to address food insecurity alongside various life circumstances. A better understanding of the lived experiences of food insecurity is paramount to address intersecting adverse health behaviors, such as smoking.

Introduction

Food insecurity in the U.S. persists as a major public health and health disparity issue, having affected 18 million households (13.5%) in 2023¹. Food insecurity is characterized by experiences such as worrying about running out of food and being unable to afford balanced meals, with more severe experiences including not eating for an entire day or losing weight due to not having enough food². Food insecurity disproportionately impacts low-income households, as well as households with single mothers, older adults, and persons living with disabilities³. Food insecurity exacerbates health risks, increasing the prevalence of certain diet-related chronic diseases such as diabetes, hypertension, and heart disease, and poses challenges to managing these conditions^4–6. Furthermore, food insecurity is linked to poorer mental health outcomes including elevated rates of depression and psychological distress.^7,8

Cigarette smoking is a leading cause of preventable death and disease in the U.S., with the prevalence of smoking inversely related to income^9,10. As a major socioeconomic stressor, food insecurity also impacts adverse health behaviors, such as cigarette smoking¹¹. Epidemiological studies of U.S. adults have consistently found that food insecurity is independently associated with higher rates of smoking and vice versa^12–15. For people who smoke and experience food insecurity, prior qualitative study findings suggest that smoking can be a strategy to feel less hungry in the midst of food hardship¹⁶, and that the life stress associated with experiencing poverty makes quitting smoking difficult¹⁷.

Although the literature shows that food insecurity and smoking are intertwined public health issues, the lived experiences of food insecurity by smoking status—that is, among people currently smoking as well as people who formerly smoked—is not well understood. This is important because studies have shown that smoking and food insecurity are risk factors for one another¹⁸, and researchers have argued for the need to address food insecurity and smoking in tandem¹⁴. Beyond quantitative studies, a better understanding of the lived experiences of food insecurity among people who smoke is needed to provide insights that can inform strategies to promote food security, nutritional health, and health behavior change more comprehensively. Furthermore, examining lived experiences offers personal accounts and perspectives that will be necessary for developing intervention approaches that are relevant, dignified, and aligned with the actual needs and experiences of members of population groups. Taken together, the present study aimed to examine the lived experiences of food insecurity, including food insecurity coping strategies, among low-income individuals who have ever smoked. Because relatively little is known about the lived experiences of food insecurity that similarly or differentially impact individuals based on current smoking status, we also aimed to understand from a more exploratory perspective of how the burden of food insecurity may vary by smoking status.

Methods

This was a secondary analysis of in-depth qualitative interviews (n=32) exploring tobacco use and food insecurity among U.S. adults. Details on participant recruitment and interview methods are published elsewhere¹⁶ and briefly summarized here. Participants were recruited in Western Massachusetts, primarily through flyers and word-of-mouth at local food pantries, as well as through flyers at other community-based organizations, local bus route advertisements, and online ads on Craigslist. The study sample included adults who self-reported experiencing food insecurity using the Hunger Vital Sign screener¹⁹, and were either currently smoking or had formerly smoked. That is, all participants had smoked 100 or more cigarettes in their lifetime; currently smoking participants were individuals who now smoke every day or some days, and formerly smoking participants were individuals who stopped smoking in the last three years, and currently do not smoke at all.

Individuals who agreed to participate and provided informed consent were interviewed by telephone between June and August 2019. The interviews lasted about one hour and used a semi-structured guide (see Table 1 for sample questions most relevant to the current study and the supplementary file for the full semi-structured interview guide) that covered topics such as current life circumstances, tobacco use behaviors, food shopping patterns, and experiences of food insecurity. Participants were compensated with a $50 gift card from a grocer of their choice for participating in the study. All study procedures were approved by the Institutional Review Board.

Table 1.

Sample of Interview Questions Most Relevant to the Current Study¹

• What is a typical day like for you? Can you walk me through a typical day? • Can you tell me about your food shopping practices? • Where do you usually get your groceries? How do you usually get there? • How often do you worry about running out of food? Do you worry about running out of food most months? Is there any pattern to running out of food? • What do you do if there isn’t enough food? What helps you deal with your food concerns?

¹The full semi-structured interview guide is available as a supplemental file.

Table 2 provides a summary of the participant demographic characteristics. Overall, the mean age of participants was 44 years (SD = 10.9 years). The majority identified as female (72%, n=23), non-Hispanic White (63%, n=20), and most (91%, n=29) reported completing a high school degree. Demographic characteristics of participants who currently smoke (n=23) and formerly smoked (n=9) were similar.

Table 2.

Participant Demographic Characteristics by Smoking Status

Characteristic	All (n=32)	Currently Smoking (n=23)	Formerly Smoking (n=9)
Demographics
Age, years, M (SD)	44.0 (10.9)	44.2 (11.5)	43.7 (9.9)
	n (%)	n (%)	n (%)
Female	23 (71.9%)	18 (78.3%)	5 (55.6%)
White, non-Hispanic	20 (62.5%)	15 (65.2%)	5 (55.6%)
African American/Black	5 (15.6%)	3 (13.0%)	2 (22.2%)
Hispanic/Latino	4 (12.5%)	3 (13.0%)	1 (11.1%)
Another Race/Multiple Races	3 (9.3%)	2 (8.6)	1 (11.1%)
Education level
Less than high school	3 (9.3%)	3 (13.0%)	0 (0.0%)
Completed high school	7 (21.9%)	7 (30.4%)	0 (0.0%)
Some college	15 (46.9%)	8 (34.8%)	7 (77.8%)
College Degree or more	7 (21.9%)	5 (21.7%)	2 (22.2%)
Employed full time or part time	15 (46.9%)	10 (43.5%)	5 (55.5%)
Participate in SNAP	16 (50.0%)	12 (52.2%)	4 (44.4%)
Unhoused or unstably housed1	4 (12.5%)	4 (17.4%)	0 (0.0%)

SNAP = Supplemental Nutrition Assistance Program

¹refers to homelessness, living in shelter, car, trailer, or couch surfing.

Analysis

All interviews were audio-recorded, professionally transcribed verbatim (removing any personal information), and checked for accuracy. We used reflexive thematic analysis as a theoretically flexible approach that is appropriate for understanding people’s lived experiences^20,21. Two independent coders read a set of transcripts and developed a list of inductive and deductive codes to create an initial codebook, which was refined with further discussion with the overall research team to clarify any discrepancies. After coding all transcripts, memos were created as the basis to identifying initial themes. Numerous discussions amongst all authors informed the revised themes presented in this study.

Results

Four themes were identified through the analyses. Two themes were related to food insecurity irrespective of smoking status: the importance of food storage and reliance on multiple types of community support. Two additional themes were specific to people who currently smoke: chronicity of food insecurity and normalization of smoking and managing weight gain concerns through continued smoking.

As an important backdrop to the identified themes that follow, structural factors such as access to food assistance, access to transportation, and housing insecurity intersected with experiences of food insecurity. For instance, all participants were users of local food pantries or community meal programs as an important means to supplement their food needs. However, only about half were participating in the Supplemental Nutrition Assistance Program (SNAP) at the time of interview. About 13% were unhoused or unstably housed at the time of interview, with situations including living in a foreclosed home, living in a trailer without running water, and living out of a car.

Transportation situations, while varied, also influenced experiences of food insecurity and participants’ choices to shop at specific food outlets. For instance, one participant’s food shopping involved a monthly excursion to spend her SNAP benefits, yet she faced challenges due to her lack of personal transportation. “The place closest to us, we’ll go buy their meats because they’re cheaper,” she stated, adding the notable detail that this retailer offered a ride home to customers spending $50 or more, “saving us on having to Uber or Lyft home.” Participants without a car also discussed the physical burden of carrying groceries and how proximity determined the food purchasing location. One participant mentioned his proximity to a convenience store and a grocery store, but the emphasis was on walking, his primary mode of transportation. When asked about visits to a food pantry, he outlined his strategy: “I put [my groceries] in a suitcase,” describing his means of transporting groceries via public transportation.

Theme 1: The importance of food storage

Participants employed various strategies to plan in advance, avoid potential food waste, and ensure that food lasts as long as possible, within the constraints of their food storage situations. For some, this entailed additional time and effort to freeze food portions for future consumption, having learned from prior experiences.

I really have to be aware, like if I buy a family pack of meat, I have to break it up pretty quickly after and make sure I freeze it right away because there have been times where I’ve bought meat and it’s gone bad. Which is such a shame in so many ways. Like I don’t have money for that, animals died and they’re not even being used. I mean, there’s so many reasons why that is the worst thing ever to do so I’ve gotten better about that because I’ve gone shopping and it’s so hard to get everything done. I think I have a couple of days to package it up and freeze it [or] it’s gone bad. (“Beth”, currently smoking female participant in early 40s)

However, not all participants had access to adequate freezers or refrigeration. One participant discussed how she and her husband continuously balanced their grocery budget alongside shopping trips, increasing the frequency of food shopping due to a lack of freezer space.

We only got probably like $130 in SNAP benefits, so they wouldn’t last long. It’d be like one shopping spree for that… We try to go food shopping at least twice a month… But we don’t have the room to really freeze all our food. We don’t have like a deep freeze or anything, so we just got to kind of really go food shopping like three times a month in order to make our food last. (“Ashley”, formerly smoking female participant in late 40s)

One participant who was unhoused and living out of her car discussed that she visited her local community meal program frequently, since she did not have access to a kitchen. The foods that she could buy with her SNAP benefits were often limited due to the lack of refrigeration and general access to proper food storage.

[I visit the community meal program] almost every day because I don’t have a kitchen. And when I had that apartment I still didn’t have a kitchen… But [I visit the meal program] probably four days a week because, unlike a lot of people there, who go there for social things and free food, if you’re homeless then it’s much more of a necessity or a need to go… My situation is that I have food stamps but if I can only get food for this moment, that’s a lot to go to Trader Joe’s or Aldi. It’s got to be something ready to eat. And I would buy a bunch of hummus but it would go bad. (“Pam”, currently smoking female participant in late 50s)

In this theme, food insecurity intersected with food storage practices and access to appropriate storage methods, with food shopping patterns dependent on one’s ability or lack thereof to properly store foods.

Theme 2: Reliance on multiple types of community support

Community support featured prominently as a strategy to cope with food insecurity. The types of community support were varied; this included receiving information and sharing tips about the best deals at specific grocery stores from friends and neighbors, to getting free food through a local “freecycle” Facebook group that occasionally posts food items, to eating foods and meals shared by others, and forming mutually beneficial relationships, such as exchanging childcare for food.

My upstairs neighbor, tonight instead of tomorrow, I’m watching her daughter. In exchange, she made me supper, so I didn’t have to use any of my food. (“Lauren”, formerly smoking female participant in mid 50s)

Well, sometimes my uncle will bring me food because he volunteers at a food pantry on Fridays and he used to bring me food, like, a lot of meats and stuff, sometimes produce, like, oranges or whatever and apples, potatoes. (“Tammy”, currently smoking female participant in early 40s)

There was a shared understanding of the experience of food hardship across participants’ social networks. One participant, a single parent whose SNAP benefits had been substantially reduced, described that her neighbor, who qualified for a meal delivery service for older adults, would share the meals they received with her.

I do get food stamps… but then they reduced it and I have my daughter half time… I only get $59 a month… And I have no money in my budget for food… I make sure my daughter is fed… As long as she has something. And like yesterday I would not have eaten dinner if I was not invited upstairs, because I cooked my last food on, I think Saturday or Sunday… there’s this program called Mom’s Meals, which I guess is for the elderly. It’s probably illegal, but one of the residents here, they’re eligible for two boxes… they get two boxes of these Mom’s Meals and so they’ve given me some of those and ordered some of those for me, especially the breakfast ones so when I have my daughter now, they’ve given me some from their order. (“Sandra”, currently smoking female participant in late 40s)

Another participant, a graduate student who lived with her boyfriend and split the household grocery shopping bill evenly with him, discussed the challenges of sticking to pre-planned meals at home and refraining from eating when spending full days at school. Because it was important for her to ensure that she only ate her fair share of food at home, she struggled with managing her hunger throughout the day. Therefore, being able to eat meals while babysitting was an appreciated aspect of the job.

Sometimes, I’ll eat before I go [to school] and then not eat the whole time. I tell myself that it’s to lose weight, but it’s not really. It’s because I don’t want to waste something. So sometimes I just won’t eat before I leave, and then I’ll come home and just eat dinner… Sometimes I eat lunch with the kids that I babysit. Like, I’m not taking their food. They just like—it’s part of the whole deal. They’re like, “Oh, make yourself some lunch,” so that’s really nice, actually… Other than that, I will try to stretch things here. I’ve gotten pretty creative with boxed powdered potatoes and shitty food, just trying to make it work. I drink a lot of water so that I can try and fill up on that before I—like if I’m feeling hungry and I don’t want to eat something. (“Emma”, formerly smoking female participant in late 20s)

In this theme, participants relied on various types of community supports as a way to deal with food hardship. There was a pronounced awareness and vigilance about managing one’s food intake in relation to the food and groceries they had on hand, exemplified by expressions such as “using” or “wasting” food to describe food consumption.

Theme 3: Chronicity of food insecurity and normalization of smoking

Participants who were currently smoking described lived experiences of food insecurity that were often chronic throughout their life, recalling prior times of food hardship along with their current struggles. Most participants had initiated smoking during their teenage years; therefore, affording to smoke while struggling to afford to eat was a normalized tradeoff. One participant was living on a fixed income and residing in a trailer without running water. He shared his current and past experiences of food insecurity:

Within the last month I haven’t had enough food for anything. There was one night I woke up and I actually had nothing. That’s kind of why I’m eating pancakes right now, because I don’t want people giving me stuff. And pancakes are the cheapest thing you can get, basically, because I don’t even care for pancakes that much. Right now, I’m trying to stretch as much as I can without having to ask for help as much as I can. But yeah, there was a few times earlier in life when I had my kids that was very tight. I always made sure my kids ate. Me, I would go without, just to make sure they had, at certain times in my life. (“John”, currently smoking male participant in late 40s)

At the same time, this participant relied on his friends to afford to smoke up to two packs per day: “[My friends] actually bought them [cigarettes] for me. But that, I’m paying them back. That was more like borrowed money.” This exemplifies that the internalized stigma related to not having enough money for food may outweigh concerns about affording to smoke. Furthermore, going without food and substituting smoking for meals had become a normalized tradeoff. It also intersected with the experience of parenting, ensuring that children have enough to eat.

I feel like if my kids were going to be needing [food], that’s different, and I would always give to them first. But for me, I guess I find the cigarettes more satisfying than anything else, or more necessary… There’s been times like at work breaks. And sometimes I don’t eat breakfast; I do just go smoke a cigarette, and that’s it. (“Tamera”, currently smoking female participant in mid 30s)

I deny myself other things [to afford to smoke], like being able to go to the movies or being able to go out to eat. (“Donna”, currently smoking female participant in mid 50s)

For many participants, the experience of food insecurity was a chronic and familiar experience that had become normalized alongside their dependence on smoking. Furthermore, the tradeoff in choosing cigarettes over food was closely intertwined with concerns about ensuring that their children had enough to eat.

Theme 4: Managing weight gain concerns through continued smoking

Many participants who were currently smoking also had numerous diet-sensitive chronic conditions, such as diabetes, hypertension, and irritable bowel syndrome, and some had prior histories of eating disorders, such as bulimia and binge eating disorder. Participants were relatively health conscious about their diets, and the lived experience of food insecurity intersected with a complex concern with a fear of gaining weight, which was viewed as a barrier to smoking cessation.

I had attempted to stop [smoking], and I stopped for like a smooth two months… I found myself gaining an extreme amount of weight, like bad…every time I wanted a cigarette or felt like I needed one, I would eat… Even when I stopped, then I was putting on all this weight, which was even more concerning to the doctors. I started smoking again because I was stressed out, and [when] I started smoking, I started losing the weight all over again. (“Leah”, currently smoking female participant in mid 30s)

I’m really trying to lose this weight, and I’m terrified I’m going start gaining weight once I quit. (“Ava”, currently smoking female participant in mid 30s)

If I quit smoking, I’d probably gain 300 pounds… My uncle quit for ten years. He gained like almost 100 pounds. He started smoking again, and he actually lost like 100 pounds. (“John”, currently smoking male participant in late 40s)

In this theme, participants rationalized continued smoking as a way to avoid weight gain, which they perceived as exacerbating existing health problems. The potential for weight gain, whether it was based on personal or vicarious prior experience, was a perceived fear, and served as a stressor that contributed directly to continued smoking.

Discussion

Food insecurity and tobacco use are intertwined and complex health disparity issues that disproportionately affect the health and wellbeing of low-income populations. This study is among the first to examine the lived experiences of food insecurity among adults with socioeconomic disadvantage who have ever smoked cigarettes, exploring the commonalities and differences in the experiences of people who currently smoke versus formerly smoked. We identified two themes that delineated the experience of food insecurity regardless of current smoking status, which related to the importance of appropriate food storage and kitchen access, as well as social factors related to reliance on various types of community supports and relationships to make ends meet. Furthermore, two themes highlighted the complexity of food insecurity experiences in its intersection with current smoking behavior, including the normalization of smoking in the midst of chronic food insecurity, and smoking to manage concerns about weight gain.

Aligned with research describing the cognitive burdens of living in poverty^22,23, participants experienced cognitive and time-related burdens related to planning for grocery shopping trips with limited funds, transportation challenges, and refrigeration access. There were special considerations to avoid potential food waste, balancing efforts to process and properly store food within individual constraints. Particularly for participants receiving SNAP, there was little margin for error in managing the food budget, as monthly benefits were often the only source of grocery budget for the month.

In addition to the regular use of food pantries and community meal programs, participants relied on their social networks and community supports to deal with food hardship. Within various definitions of food insecurity, food insecurity has been previously described to exist “whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain”²⁴. This was echoed throughout participants’ lived experiences, particularly in relying on coping strategies such as eating non-preferred foods lacking in nutrients, drinking water to feel full, and acquiring food in ways that may not be considered socially acceptable. On the other hand, such strategies served to illustrate a particular form of social capital—bonding social capital—which describes trusting and cooperative relationships within members of groups sharing similar sociodemographic characteristics²⁵. The extent to which social capital can protect against or lessen food insecurity is not yet well understood. Prior research applying the different facets of social capital to the understanding of food insecurity experiences have ultimately highlighted the importance of structural interventions that go beyond enhancement of social capital²⁶. Nevertheless, the current results provide additional support that leveraging social capital is one strategy to deal with food insecurity.

Prior studies have suggested that food insecurity is paradoxically related to higher body weight and obesity, particularly for women^27–29. Although the exact mechanisms are not yet clear, researchers have posited that resource scarcity has cognitive, psychological, and physiological effects that favor energy conservation and weight gain^28,30. Compensatory strategies for food insecurity also include overconsumption during times of food adequacy to avoid food waste and to anticipate times of food scarcity, as well as reliance on lower-cost, high caloric foods³¹. Over time, this can collectively impact the development and progression of diet-sensitive chronic diseases^4,31. As nicotine suppresses appetite,³² prior study findings have described smoking as a strategy to ignore hunger and eat less when faced with food insecurity¹⁶. For currently smoking participants, many of whom had diet-sensitive chronic conditions such as diabetes and hypertension, personal experiences and anecdotes shaped concerns about potential weight gain as a barrier to smoking cessation. This is in line with the broader literature showing that weight gain concerns are a barrier to smoking cessation³³, and that some amount of weight gain after cessation is not uncommon³⁴. However, it is critical to note that quitting smoking offers substantial benefits to health even when there is weight gain³⁵, and that the perceived health benefits of preventing weight gain by smoking compared to the health risks of continuing smoking are not comparable. Shifting health perceptions about body weight relative to smoking will be important for future work, particularly as findings from a randomized trial showed that the degree of weight gain concerns prior to cessation treatment was unrelated to actual weight change in a 12-month follow-up³⁶. Findings from this study suggest the need for future research on more nuanced insights into the relationship between food insecurity, chronic disease, body weight, and smoking cessation, to inform effective cessation interventions for this group.

The current findings should be interpreted within the study limitations, which also provide a basis for future investigations on this topic. There was a higher proportion of currently smoking versus formerly smoking participants in the study sample, and as such, theme comparisons by smoking status are considered exploratory. With this caveat, the two themes that were specific to currently smoking participants suggested that reducing food intake was a particular tradeoff made to be able to afford to smoke, and that smoking was rationalized in light of other health-related concerns. These factors may represent unique barriers to smoking cessation in this group that may need to be addressed in the context of cessation treatment. We did not find themes specific to formerly smoking participants, which may be related to the small sample size, the study eligibility criteria, and/or the interview questions. For instance, as all participants regardless of their current smoking status were screened as food insecure at the time of the interview, this prevented understanding of potential changes in food insecurity situations as a result of quitting smoking. Recent population-based findings suggest that quitting smoking is associated with improvement in food security³⁷, and future research could address this gap, both qualitatively and in the context of cessation treatment. Given the study’s geographic context and recruitment methods, the findings may not necessarily be transferable to other population groups experiencing food insecurity. The interviews were conducted prior to the onset of the COVID-19 pandemic, which had wide-ranging impacts on food insecurity^38,39. Although lived experiences of food insecurity may have acutely differed during and as a result of the pandemic, the current findings may nevertheless be relevant by providing a pre-pandemic baseline as a potential comparison for future investigations.

As one of the first studies to explore the lived experiences of food insecurity among people who currently smoke and formerly smoked, the findings presented here illustrate a complexity of factors that impact both food insecurity and smoking behavior. Rather than addressing such public health and health disparity issues in isolation of one another, the findings illustrate the need to address intersecting factors that are more closely aligned with people’s lived experiences.