Tobacco use is a major public-health concern in the United States. Intervention and prevention strategies for tobacco use are an urgent public-health priority because tobacco use is the single most preventable cause of death. To help social workers better understand tobacco use problems, this entry presents an overview, including definitions of terms, the scope and impact of tobacco use problems in terms of different segments of the population (that is, age, gender, race or ethnicity, geographic location, and education level or socioeconomic status), etiology of tobacco use (for example, biological or genetic; psychiatric; psychosocial; or environmental or sociocultural factors), policy history, tobacco prevention, clinical issues (such as cessation desire, treatment and success, or screening tools for tobacco use disorder and tobacco withdrawal), and practice interventions for tobacco use problems. Based on the information, the roles of social workers will be addressed.
Mansoo Yu and Rachel Fischer
Philip DeCicca, Donald S. Kenkel, Michael F. Lovenheim, and Erik Nesson
Smoking prevention has been a key component of health policy in developed nations for over half a century. Public policies to reduce the physical harm attributed to cigarette smoking, both externally and to the smoker, include cigarette taxation, smoking bans, and anti-smoking campaigns, among other publicly conceived strategies to reduce smoking initiation among the young and increase smoking cessation among current smokers. Despite the policy intensity of the past two decades, there remains debate regarding whether, and to what extent, the observed reductions in smoking are due to such policies. Indeed, while smoking rates in developed countries have fallen substantially over the past half century, it is difficult to separate secular trends toward greater investment in health from actual policy impacts. In other words, smoking rates might have declined in the absence of these anti-smoking policies, consistent with trends toward other healthy behaviors. These trends also may reflect longer-run responses to policies enacted many years ago, which also poses challenges for identification of causal policy effects. While smoking rates fell dramatically over this period, the gradient in smoking prevalence has become tilted toward lower socioeconomic status (SES) individuals. That is, cigarette smoking exhibited a relatively flat SES gradient 50 years ago, but today that gradient is much steeper: relatively less-educated and lower-income individuals are many times more likely to be cigarette smokers than their more highly educated and higher-income counterparts. Over time, consumers also have become less price-responsive, which has rendered cigarette taxation a less effective policy tool with which to reduce smoking. The emergence of tax avoidance strategies such as casual cigarette smuggling (e.g., cross-tax border purchasing) and purchasing from tax-free outlets (e.g., Native reservations in Canada and the United States) have likely contributed to reduced price sensitivity. Such behaviors have been of particular interest in the last decade as cigarette taxation has roughly doubled cigarette prices in many developed nations, creating often large incentives to avoid taxation for those who continue to smoke. Perhaps due to the perception that traditional policy has been ineffective, recent anti-smoking policy has focused more on the direct regulation of cigarettes and smoking behavior. The main non-price-based policy has been the rise of smoke-free air laws, which restrict smoking behavior in workplaces, restaurants, and bars. These regulations can reduce smoking prevalence and exposure to secondhand smoke among nonsmokers. However, they may also shift the location of smoking in ways that increase secondhand smoke exposure, particularly among children. Other non-tax regulations focus on the packaging (e.g., the movement towards plain packaging), advertising, and product attributes of cigarettes (e.g., nicotine content, cigarette flavor, etc.), and most are attempts to reduce smoking by making it less desirable to the actual or potential smoker. Perhaps not surprisingly, research in the economics of smoking prevention has followed these policy developments, though strong interest remains in both the evaluation of price- and non-price policies as well as any offsetting responses among smokers that may undermine the effectiveness of these regulations. While the past two decades have provided fertile ground for research in the economics of smoking, we expect this to continue, as governments search for more innovative and effective ways to reduce smoking.
Cigarette smoking in the People’s Republic of China (PRC) is a highly gendered practice. The vast majority of China’s three hundred million plus smokers are men: in 2016, about 48 percent of men over age 15 were current smokers, but less than 2 percent of women smoked. The stark difference in this pattern of men and women’s smoking behavior is often attributed to lingering cultural taboos against female smoking assumed to have been in place for centuries. In fact, the virtual exclusivity of male smoking in China is of relatively recent vintage, dating only from the mid-1900s. From the 17th to the 19th centuries, smoking was socially acceptable for Chinese women. Granted, there were gendered and class differences in the location of tobacco consumption. Chinese men could smoke in public, but well-mannered women smoked privately out of view. After cigarettes were introduced into China at the end of the 19th century, some women, especially those living in coastal cities, took to smoking them rather than pipe tobacco. In the opening decades of the 20th century, the number of women who smoked cigarettes increased, but this trend was reversed in the 1930s and 1940s. After the establishment of the PRC in 1949, the number of women who smoked diminished even further such that by the 1980s, only a small percentage of women consumed tobacco products of any kind. Many social, economic, and cultural factors contributed to the gendered pattern of smoking that emerged in China over the course of the 20th century. An essential aspect of this history was the transformation in social norms that made cigarette smoking less rather than more respectable for women as time went on. At the beginning of the century, many women were already accustomed to smoking pipe tobacco. Some women, including those who identified as forward-looking “New Women,” preferred cigarettes. However, by mid-century cigarettes came to be widely associated with a stigmatized type of New Woman known as the “Modern Girl.” Portrayed in popular culture and political rhetoric alike as extravagant and sexually promiscuous, the Modern Girl’s pursuit of luxury came to symbolize bourgeois decadence and insufficient national loyalty. These associations came forward into the PRC period and as a result, most women born after 1949 elected not to smoke at all. Major differences in male and female smoking prevalence rates persist because female smoking remains objectionable to many Chinese citizens in the 21st century.