Martinsville, Va.
That is, unless those Americans are poor, uneducated or live in a rural area.
Hidden among the steady declines in recent years is the stark reality that cigarettes are becoming a habit of the poor. The national smoking rate has fallen to historic lows, with just 15 percent of adults still smoking. But the socioeconomic gap has never been bigger.
Among the nation’s less-educated people — those with a high-school-equivalency diploma — the smoking rate remains more than 40 percent, according to the Centers for Disease Control and Prevention. Today, rural residents are diagnosed with lung cancer at rates 18 to 20 percent above those of city dwellers. By nearly every statistical measure, researchers say, America’s lower class now smokes more and dies more from cigarettes than other Americans.
This widening gap between classes carries huge health implications and is already reshaping the country’s battle over tobacco control. Cigarette companies are focusing their marketing on lower socioeconomic communities to retain their customer base, researchers say. Nonprofit and advocacy groups are retooling their programs for the complex and more difficult work of reaching and treating marginalized groups.
As inequality in America continues expanding by many measures, smoking is a growing aspect of that divide that is a matter of life and death, with wealthier and more-educated Americans now largely spared the cost and deadly effects of the vice.
Advocacy groups say funding for smoking cessation is dropping, and they worry the attention and political will needed for tobacco control is also waning as America’s upper and middle classes see smoking as an already solved, bygone problem.
“If you’re educated and live in a well-off area, the smoking problem we’re talking about these days is now largely invisible to you,” said Matthew Myers, president of the Campaign for Tobacco-Free Kids. “In some places, you can go days without bumping into a smoker. So you start to hear the question, why push more resources into this? Meanwhile, the need is getting even greater, because the people left smoking are the ones who can least afford to.”
Debbie Seals, 60, has fought on the front lines of this new class battle for the past six years from her home in the rural foothills of Virginia’s Blue Ridge Mountains.
She has driven her tiny blue Fiat to the farthest corners of southern Virginia and West Virginia to hold classes aimed at helping smokers quit. Her cessation clinics are often the only ones offered for miles around.
“It’s like there’s two worlds now,” Seals said.
Every month, she travels to Northern Virginia to visit her grandchildren in the D.C. suburbs. In Alexandria, she sees couples jogging on the streets and buying expensive organic groceries at Whole Foods — and not a single one smoking.
But in her home town of Martinsville, Va., cigarettes are ubiquitous. People smoke on their morning drive to work and on weekends mowing their lawns. Tobacco stores line the strip malls, and cigarette ads are in the windows of every gas station and convenience store.
The smoking is a symptom of deeper problems here, Seals said on a recent afternoon as she headed out to check on three former students from her cessation class.
Martinsville was once known as the “Sweatshirt Capital of the World,” a booming center of textile mills and furniture factories. Now it is littered with abandoned factories and vacant storefronts. So many families here live in poverty that all children in elementary and middle school automatically qualify for free and reduced-price meals.
“People down here smoke because of the stress in their life,” Seals said. “They smoke because of money problems, family problems. It’s the one thing they have control over. The one thing that makes them feel better. And you want them to give that up? It’s the toughest thing in the world.”
Seals — who retired years ago from a career with Girl Scouts of the USA — began teaching her classes as a volunteer for the American Lung Association. After seeing the desperate need, she began working full time on cessation for the nonprofit.
She’s taught many classes in recent years at the handful of furniture factories left. Many of the participants attend her clinic over and over, unable to stop smoking. She is careful not to make any of them feel like failures.
“If they manage to quit for a week or even a day, they succeeded,” she said. “I tell them if you were able to quit once, you can do it again.”
Meeting up with three of her former students at a diner last week, Seals probed gently, asking how much they are smoking these days.
“I’ve slid back,” admitted Victoria Cassell, 57, who has attended Seals’s seven-week program every year for four years. “There was just too much going on in my life last year.”
First, Cassell’s sister died. Then her husband started having heart problems again. On top of it all, her daughter and grandson moved back in.
The last time Cassell tried to quit was three months ago, after a doctor’s test gave her a lung cancer scare. “It was like losing my best friend,” she said. “My cigarettes have kept me company for 40 years, longer than just about anyone in my life.”
She ate lunch alone at the factory where she works, because her friends all smoke. She tried coloring while watching TV, just to keep her hands busy.
Three days in, an argument with a co-worker pushed her over the edge, she said. She ran to a friend at her first chance to bum a cigarette.
It wasn’t always this way.
When smoking first gained popularity in the early 20th century, it was a habit of the rich, a token of luxury dusted with Hollywood glamour. Then came the 1964 surgeon general’s report on its deadly effects, and during the next 3½ decades, smoking among the nation’s highest-income families plummeted by 62 percent. But among families of the lowest income, it decreased by just 9 percent.
“There’s this tendency now to blame the ones still smoking,” said Robin Koval, president of Truth Initiative, a leading tobacco-control nonprofit group. “The attitude is, ‘You’re doing it to yourself. If you were just strong enough, you’d be able to quit.’ ”
What isn’t taken into account, Koval said, are the vast resources tobacco companies are spending to hold onto their last remaining strongholds.
In recent years, studies have found those companies’ discounts often target low-income and minority communities. New research also shows that lower-income neighborhoods have a much higher density of tobacco retailers.
“Poorer people don’t smoke because anything’s different or wrong about them,” Koval said. “Their communities are not protected like others are. They don’t have access to good health care and cessation programs. If you have a bull’s-eye painted on your back, it’s harder to get away.”