Nov. 6, 2017 | It’s hard to quit smoking. Ask anyone who has tried and failed and tried again, sometimes in a seemingly endless cycle.

This process of quitting is important for individuals and their personal health, but there are also bigger concerns at stake, specifically how smoking affects our society as a whole.

This complex issue is of vital interest to public health researchers who spend their time trying to understand why some population groups are more likely to smoke than others and what strategies will help them quit once and for all.

Pebbles Fagan, Ph.D., M.P.H., is one of those researchers. Now entering her second year as director of the UAMS Center for the Study of Tobacco in the Fay W. Boozman College of Public Health, Fagan has devoted her career to studying tobacco control and cancer prevention. Specifically, her interest lies in reducing tobacco-related health disparities among underserved populations.

That expertise has recently resulted in the publication of a six-year-long project she conceived of while serving as a health scientist in the Tobacco Control Research Branch at the National Cancer Institute (NCI) in Bethesda, Maryland.

“A Socioecological Approach to Addressing Tobacco-Related Health Disparities” is the 22nd volume in a series of monographs addressing issues related to tobacco control. Monographs are detailed studies written about specific topics.

The NCI established the Tobacco Control Monograph series in 1991 to provide information about emerging public health issues in smoking and tobacco use control.  Fagan served as scientific advisor, writer and editor for this monograph — the first to focus on tobacco-related health disparities.

After initiating the project, Fagan asked Linda Alexander, Ed.D., associate dean of academic affairs at the West Virginia University School of Public Health, to serve as editor. Together, they recruited more than 50 subject matter experts to write and contribute chapters on the impact, causes and trends in tobacco-related health disparities.

“What’s unique about this monograph, is that it’s the first comprehensive document to focus on tobacco-related health disparities since the publication of the 1998 surgeon general’s report on tobacco and minorities,” Fagan said, adding that while that report, titled “Tobacco Use Among U.S. Racial/Ethnic Minority Groups,” focused only on racial and ethnic minorities, this monograph encompasses a broader spectrum.

“We include a focus on how issues such as poverty, educational attainment and gender affect tobacco use. We also highlight some of the issues with the LGBTQ population, as recent studies have shown this group to have a higher use of tobacco than other groups,” she said.

For Fagan, the most significant conclusion derived from the monograph centers on the varying speeds in which some groups benefit from declines in tobacco use versus others.

“Overall, tobacco use has declined, and we have evidence that shows which practices have effectively influenced this trend. This includes such things as a cigarette taxes that increase the cost of the product or receipt of advice to quit smoking from a health provider such as a doctor or dentist, , as well as statewide policies that prohibit smoking in the workplace, restaurants and bars,” she said.

What remains to be answered is why some groups benefit from these practices — and gain the resulting health benefits — more quickly than others. The answer, Fagan said, may lie in part in the applicability of different interventions for various cultural groups and the social context in which the interventions occur for different groups.

“While we know the practices that help people quit smoking, it remains to be seen if these practices work the same way for all groups or if they need to be adapted in order to be effective across cultures,” she said.

One of the groups significantly affected by smoking and tobacco-related disease is those who live in poverty. Research outlined in the monograph shows that social factors play a major role in this correlation and can run the gamut from cigarette ads at gas stations to the lack of primary care physicians in rural areas.

“In the rural Delta, for example, access to primary care providers is quite limited. People in the Delta don’t have doctors to advise them to quit or prescribe nicotine replacement therapies. This could influence why they are not benefiting from these practices at the same rate as other groups,” Fagan said.

Arkansas, and other states, also have a long way to go in implementing comprehensive clean air policies for public places, as well as encouraging families to restrict smoking in the home. These in-home practices are particularly important for African-American families, as they are twice as likely to be exposed to second-hand smoke in the home as other groups.

“We have a lot of progress to make in helping people understand that when they prohibit smoking in their home they are protecting their children from asthma, as well as protecting themselves and their children from lung cancer, heart disease and other chronic diseases caused by tobacco,” Fagan said.

In addition to the dangers of smoking, the monograph also highlights the changing landscape of tobacco control, including the rise in popularity of e-cigarettes and other new products that heat, rather than burn, tobacco.

For Fagan, the main takeaway message from all of the combined research is that regardless of any of other factors, tobacco use is dangerous.

“There is no safe use of tobacco. That’s the most important message to communicate to all groups,” she said.