Everyone deserves a fair and just opportunity to be as healthy as possible. To improve health equity, we must consider the role of commercial tobacco.  Commercial tobacco products are products sold in retail outlets and are different from traditional tobacco that is used by Tribal communities for sacred, spiritual, or medicinal purposes.  Learn more about traditional tobacco from the National Native Network.  

Communities can be places for connection and identity, but they can also be places where social and environmental factors drive disparity.  Health disparities are differences in health outcomes that are closely linked with social, economic, and/or environmental factors.  Disparities in commercial tobacco use, secondhand smoke/vaping aerosol exposure, related health problems, and access to treatment exist based on:

• where people live
• type and amount of employment
• health insurance status
• social and demographic factors including race, ethnicity, gender identity, age, sexual orientation, disability status, level of education, income, culture, language spoken, and/or behavioral health status  

These are drivers of tobacco-related health disparities.  When people face many forms of stress—like financial problems, discrimination, or unsafe neighborhoods—they can be more likely to smoke.^31,32,33  Communities experiencing tobacco-related health disparities include LGBTQ+ people^†, people lacking financial means and/or experiencing poverty, communities of color (including people who identify as Hispanic and/or Latino, people who identify as Native American or American Indian, people who identify as Asian and/or Pacific Islander, and people who identify as Black and/or African American), people with mental and behavioral health conditions, and people living in rural areas.  

^†The term “LGBTQ+” on this page to refers to people who are lesbian, gay, bisexual, or transgender, with the plus sign indicating inclusion of people who are queer, questioning, intersex, asexual, or who hold other gender/sex/romantic identities not specifically identified. Many studies cited on this page only looked at certain groups within the greater LGBTQ+ community. When single terms like “gay” or “lesbian,” or acronyms like “LGBT” are used on this page, this corresponds with how terms are used in the cited studies.

Commercial Tobacco-Related LGBTQ+^† Health Disparities 

• Most LGBTQ+ people say they have experienced some form of harassment or discrimination because of their sexual orientation or gender identity. More than half have had slurs used against them, and 57% report that they or a close friend have been threatened with violence.^34,35
• LGBTQ+ youth who attend schools with LGBT-friendly policies and student groups are less likely to begin smoking.³⁸
• Commercial tobacco advertising and marketing increase the chance that someone will try smoking for the first time or will start using commercial tobacco products regularly.^7,19,20,21  Consider the following facts about commercial tobacco advertising and marketing in relation to LGBTQ+ people:
  • Commercial tobacco advertisements are featured heavily in publications with gay and lesbian readership²³
  • Commercial tobacco advertisements are prominent at festivals and other community events held by and for LGBTQ+ people 
  • Menthol cigarettes are marketed heavily to LGBTQ+ people, which helps explain why about 36% of LGBTQ+ people who smoke use menthol cigarettes compared to 29% of straight people who smoke.²³

How LGBTQ+ People Experience a Health Burden from Commercial Tobacco

The drivers of tobacco-related health disparities above help explain the following:

• In 2021, 17.4% of gay, lesbian, or bisexual high school students currently used any tobacco product – compared to 11.4% of heterosexual high school students.³
• Lesbian, gay, and bisexual adults have more stress-related risk factors for cardiovascular (heart and blood vessel) disease – like high blood pressure – than straight adults.^5,6 Cigarette smoking can cause and worsen cardiovascular disease.⁷
• Cigarette smoking is the leading cause of lung cancer in all Americans and is linked to at least 11 other types of cancer.⁷ Given that an estimated 45,000 LGBTQ+ people die from cancer each year,⁸ it is important to understand the causes of cancer in this population.
• Gay, bisexual, and other men who have sex with men (MSM) are the population group most affected by HIV in the US, with MSM accounting for 69% of all new HIV diagnoses.^9,10 People living with HIV, including those who have access to freely available and well-organized HIV treatment, now lose more years of life from smoking than from HIV.¹¹  Cigarette smoking suppresses the immune system, making it harder to fight infections.  

Commercial Tobacco-Related Low Income Health Disparities

The pressures of poverty and/or of living in an under-resourced area help explain why health problems caused by commercial tobacco use tend to be worse for people with low socio-economic status (SES).   

• People with lower income have less access to health care, including affordable health care needed to address smoking-related morbidities.¹⁶ People who have unmet needs (including economic or job instability, lack of housing) are more likely to go to the emergency room (ER), to miss medical appointments, and to have unmanaged medical conditions^17,18.
• People who are uninsured often do not receive clinical screening (including tobacco use and cancer screening), routine care, or recommended care due to out-of-pocket cost¹⁹ and are more likely to experience delayed access to health care²⁰ which can result in adverse health outcomes.²¹
• People with low-income are more likely to live in neighborhoods where most people rent (versus owning their own home).  This impacts the quality of education that is available to them because public K–12 schools are funded primarily through local property taxes.¹²  Lower quality education is associated with lower health literacy, fewer opportunities for employment, less ability to access healthy food, and less access to health care, all of which negatively impact health outcomes.¹¹ 
• Commercial tobacco advertising and marketing increase the chance that someone will try smoking for the first time or will start using commercial tobacco products regularly.^7,19,20,21  Consider the following facts about commercial tobacco advertising and marketing in low-income areas:
  • Low SES neighborhoods tend to have more stores selling and advertising commercial tobacco products.²⁶ 
  • Schools that have a larger proportion of low-income students more likely to have nearby stores selling commercial tobacco products.²⁸
  • Low SES communities are saturated with advertising and sales of flavored cigarettes and cigars—especially menthol flavored products. This can help explain why people with lower income and less education smoke menthol cigarettes at a higher rate than groups with higher income and more education.^34,35

How People with Low Socioeconomic Status Experience the Burden of Commercial Tobacco

• People with lower income have higher incidence of commercial tobacco-related diseases than people with higher levels of income.²
• Current tobacco product use is higher among adults who were uninsured (27.3%), enrolled in Medicaid (28.6%), or had some other public insurance (21.3%) compared to adults with private insurance (16.4%) or Medicare only (12.5%).³
• People with annual family incomes of less than $12,500 have higher lung cancer incidence than those with family incomes of $50,000 or more.⁵
• People with low SES are more likely to be diagnosed with diabetes.⁶ The risk of developing type 2 diabetes is 30 -40% higher for people who smoke cigarettes than for people who don’t.⁷

Commercial Tobacco-Related Health Disparities in Communities of Color

• Hispanic and/or Latino people
• Native American or American Indian people
• Asian and/or Pacific Island people
• Black and/or African American people

Commercial Tobacco-Related Health Disparities among People with Mental and/or Behavioral Health Conditions

Commercial Tobacco-Related Health Disparities among People Living in Rural Areas