The poor are stressed, not stupid

Via Andrew Sullivan, Keith Humphries in the Washington Post asks Why have the wealthy quit smoking while the poor have not? While I wouldn’t describe the article as offensive, I think it does embody something that is. I’m talking about the miserable quality of our media’s discourse on issues relating to poor and working class Americans.

Now, I’m not a researcher on this topic but a few possibilities come to my mind. Unfortunately, the ones that seem most obvious to me are totally unmentioned in the article. It’s emblematic of how badly the media understands the lives of poor people and how subsequently bad it makes them at educating middle and upper class Americans on the facts of life faced by those at the bottom.

First, let’s look at the causes Humphreys does mention. First, he says poor smokers get more addicted because they smoke harder:

1) Lower income smokers take longer and deeper drags on each cigarette than their remaining better-off counterparts.  This strengthens their addiction (e.g., craving) and makes it more difficult to turn a resolution to quit into an enduring change.

He links to a firewalled research paper that ostensibly supports that conclusion, but since I haven’t paid the $19 for it and neither have you, I guess we’ll take his word for it. But from the summary, the paper appears to be saying that higher taxes cause smokers to inhale more deeply so as to extract more nicotine and, I suppose, increase the value proposition of the cigarettes. This may be true but I’m suspicious that this is a big factor. With smoking rates nearly three times higher for low-income workers than for the rich it seems like this can’t possibly explain more than a point or two. I guess I’m just suspicious because I have smoked and I have been in that 6-11K income bracket and I’ll tell you, the idea that I would inhale more deeply as cigarettes got more expensive seems kind of ridiculous. I can tell you there are far bigger factors, but I’ll get to those in a second.

The second claim – the wealthy face more peer pressure:

Because income tends to segregate where people work and live, poor smokers often have to make quit-attempts alongside people who are continuing to smoke, but wealthier smokers usually do not.  The last physician in a hospital who still smokes will face social disapproval from colleagues for smoking and receive social approval from those same individuals for quitting; the first worker on a roadside cleanup crew who tries to quit may face precisely the reverse social incentives from his smoking coworkers.

Ok, fine, but at best this effect tells us that there is some snowball effect at work here. That makes sense, but it doesn’t address what started the ball rolling in the first place. Why did the wealthy start quitting in greater numbers? Where do these peer pressures come from, and why do they diverge with different income levels?

His third point is that the poor have less access to resources that help a person quit smoking:

Although lower income people’s access to health care is being improved by the Affordable Care Act, they are still likely to lag middle class people in their access to effective smoking cessation treatments.  They also may face challenges in accessing care for co-occurring mental health problems (e.g., depression) which make quitting smoking more difficult.

Of the three, this comes closest to addressing some of the real-life issues that might keep a person hooked on cigs. But – and again, while I am a professional researcher, I have done zero real research on this topic – how many of the wealthy quitters got help from their doctors or therapists when they quit? According to the American Cancer Society the vast majority of quitters (91.4 percent) quit by going cold turkey. Only 6.8% of former smokers quit using drug therapy and/or counseling. This negates Humphreys’ point, at least the way he states it. However, I think health care access likely does help insofar as just having a person with medical authority tell you every year or so “you really need to quit smoking” probably makes a big difference.  (Now, I study I would like to see but never will would study how often doctors tell their wealthy patients to quit versus their poor patients).

These are three things worth considering, but they totally leave out the factors that seem most important and obvious to me. If you walked down the street in Detroit and found a smoker who made $11k per year and you asked them “Why do you still smoke?” Or “What has prevented you from quitting smoking?” What do you think they’d say? Do you think they would say “I smoke because of my health insurance status?” Do you think they’d say “I smoke because my friends do?” Let me tell you, as someone who has been extremely poor and who has smoked during poverty, why poor people don’t quit:

1. Quitting smoking is very stressful, and stress is more risky to poor people. The quitting process fills your brain with stress chemicals, makes you irritable, and makes any small stressful occurrence in your day feel like a major catastrophe. It can be seriously exhausting. This creates more risk for poor people than for the wealthy. If the boss has a nic fit and starts biting people’s heads off he might face some disgruntled workers, but he’ll be fine. If an employee experiences nic-withdrawals and bites off the boss’ head it can mean serious consequences ranging from losing hours to being passed up for raises or promotions or even job loss if their boss is a serious dick. How safe is your job as a Wal-Mart cashier if you have a chemical reaction going on in your brain that makes you apt to snap at customers and managers both? On the home front, what happens when you have that huge, loud blowout with your spouse because your brain is making you see red? If you’re wealthy, you get a motel room or crash with a friend or retreat to separate areas of the house. If you’re poor the cops come, maybe haul you off, maybe you’ve violated your probation, maybe you get locked up or fined more money you can’t afford. Stress is a bigger problem for the poor and they have ever rational reason to avoid it.

2. Stress causes relapse, and the poor are under more stress. For those who do try to quit, there are more obstacles when you are poor and forced to navigate a life full of stressors. Car broke down? Got a speeding ticket? Kid got a cold? Common occurrences for most people. For the wealthy, not a big deal. For a poor person any of those speedbumps can be catastrophic events. The article doesn’t mention success rates, but I’d bet a lot of money that poor people who do try to quit relapse more often and more quickly.

3. When you are really poor, that cigarette may be the best damn part of your day. I’m serious. When you make $9.00 per hour getting hung up on, yelled at, or spending your days sandwiched between shitty customers and shitty bosses, smoking becomes a bright spot in the day. When you get off work having a beer and a cigarette can feel like oxygen. I’m sure if Gwynneth Paltrow smoked she’d view it as a shameful dirty-dirty and she’d hide her face and she’d quit as soon as possible, all the while distracting herself with gluten-free vegan tofu livornese and trips to Bora-Bora. But being poor can make life really suck, and when life really sucks booze and cigarettes (and other drugs) can sometimes be the only respite within reach. Giving them up might make you feel physically healthier, but going without one of the only simple pleasures your life holds is a more serious sacrifice for the poor than for the wealthy.

4. Poor people have more immediate worries. When you are wealthy and life is pretty much going your way, worrying about your smoking habit giving you cancer seems like something you really ought to worry about right now. Also, cancer doesn’t care about your paycheck. Which is to say that as one gets richer, many of life’s worries fade away which has the effect of pushing health concerns up toward the top. (Indeed, the reason medical science has been such a success story for the human race is that the rich get sick too. If the rich died in famines we’d have eliminated that with ease long ago). When you are poor, your priority list looks a little different. Worrying about your life 20 years from now is a luxury that you don’t have time for when you have to worry about your life next week.

5. Have you looked around in a poor neighborhood lately? This seems like the most obvious omission to me. When you walk around a poor neighborhood you see stores on every corner advertising, on the outside, liquor, beer, wine, lottery and cigarettes. When do you think the last time was that David Koch saw a sign advertising a two-for-one deal on Newports? This phenomenon is well-known, oft-discussed, usually cited in any discussion of the socioeconomics of smoking, and seems glaringly absent here.

My big problem with the article is that it talks about the lives of poor people without seeming genuinely interested in the lives of poor people at all. If you just asked a a handful of smokers who make $15k per year, they’d be able to give you ten times the insight that this article does.

What’s worst though is what you see in the comments (I know) where people link smoking with education. I bring it up not just because of internet comments. It’s very often cited in articles like this (to his credit, Humphreys has avoided it) about smoking, and you see the same thing in articles about all sorts of other problems that plague poor people’s lives. Yes, there is a correlation between smoking and education. The more educated people are, the more likely they are to quit smoking. Too many people stop there. That’s the story. Poor people are dumb. If we just send them to college they’ll learn that smoking is bad.

This is total bullshit. No one goes to college and takes “Smoking is bad for your health 101″. In the last 4 decades or so, the vast majority of anti-smoking education has taken place on television; a medium consumed in greater quantities by the poor. And if poor people smoke more and get more cancer, that means poor people have watched more of their relatives die of smoking-related cancers. They know smoking is unhealthy. They know better than anyone.

This is a problem I have with a certain vein of liberal thought that places education at the center of anti-poverty efforts. The implication is that poor people just don’t know things. They just don’t know how to not be poor. We’ll get them in night school, and then we can teach them that stealing is bad, crack is whack, and smoking is bad. And once they have degrees they can go out and just grab one of those high-skilled jobs that grow on trees in Detroit.

To the contrary, what I think we see is that it is the wealthy and middle classes who are uneducated on matters of poverty. Harvard doesn’t offer classes in how to set up payment plans for your electric and water bills. No one at Yale has had to learn that if you don’t have money for a dentist you can buy fish antibiotics at the pet store that will clear up an oral infection. And apparently, no one has been taught about why poor people smoke.

ADDENDUM:

I started wondering about a big gap in this whole narrative. All the studies seem to talk about the demographics of people who quit smoking. But the speculations that are being made often relate not to quitting but to trying to quit. Is it that poor people try to quit less often than wealthy people, or is it that poor people are less successful at quitting? That’s important. Well, I did some googling and I had a hard time finding answers, but I did find a summary from this study that says:

Except for an inverse association with age, attempting to quit was not associated with sociodemographic variables.

If that’s true it’s interesting and important. It means poor people try to quit just as much as wealthy people but are just a lot less successful at it. Vital information if you’re trying to answer the questions Humphreys is looking at.

My beef with Humphreys’ article, though, isn’t that he got this wrong, or that he talked about education. He made no mention of education and he rightly concludes that poor people have a harder time quitting. My beef is that the way he talk about poor lives omits much of their reality which leaves the door open for lots of the typical anti-poor bias. I’ve lived many years as a very poor person in America who smoked, and I don’t see an ounce of my experience in his article. I want to see people speaking about the poor. I’d really love to see poor people speaking about being poor, but if the closest I’m going to get to a voice for the poor is Keith Humphreys’ well-meaning article, then I’d like it to at least resonate with the basic realities they face.

I’m not troubled by this article specifically. I’m troubled by the general distance I see between contemporary liberals and poor people. I think your average white center-left plugged-in Clinton supporting liberal has very little idea what it’s like to be poor in America. Liberals have spent too long talking about poverty as if it’s a complex web of environmental factors that we can fix with social work, health policy, housing policy, etc. It’s time to consider that poverty is not a product of the poor and that we can’t solve it by changing poor people’s behavior. You don’t solve poverty by giving money to health insurance companies, researchers, social workers, NGOs, policy institutes, Democrats, small businesses, or schools. You solve poverty by giving money to poor people.

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