Smoking Has More Impact Than Low Socioeconomic Status, Psychological Distress on Risk of Cardiovascular Disease
Key findings
- This study used a computer simulation to investigate how smoking disparities contribute to disparities in cardiovascular disease (CVD) incidence in the U.S.
- The model-projected impact of smoking on 20-year cumulative incidence of CVD was considerably larger than the impact of low socioeconomic status (SES) or serious psychological distress (SPD) themselves
- While health consequences can arise from low SES and SPD, researchers found that differences in CVD incidence between these groups and their non-marginalized counterparts were due more to smoking than any other health risks associated with those statuses
- If those in the U.S. with low SES or SPD had smoking prevalence and trends that matched their higher SES and non-SPD peers, there would be 6.2% (lower SES) and 11.3% (SPD) fewer new cases of CVD
- Interventions that specifically focus on smoking in marginalized subpopulations are important to reduce disparities in CVD risk
U.S. individuals with low socioeconomic status (SES) or serious psychological distress (SPD) are more likely to smoke than their less marginalized counterparts, and they also have a disproportionately higher burden of cardiovascular disease (CVD). However, whether higher smoking rates cause this greater CVD burden hasn't been clear.
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Now, in the American Journal of Preventive Medicine, a research team at Massachusetts General Hospital presents evidence that reducing tobacco disparities may reduce CVD burden in these marginalized subpopulations.
The authors are Krishna P. Reddy, MD, MS, a physician in the Mass General Division of Pulmonary and Critical Care Medicine, Douglas E. Levy, PhD, an investigator in the Mass General Tobacco Research & Treatment Center, Boram Lee, PhD, a fellow in the Tobacco Research and Treatment Center, Linzy V. Rosen, BA, of the Mass General Medical Practice Evaluation Center, and colleagues.
Using Computer Modeling to Make Predictions
Drs. Reddy, Levy, and colleagues previously developed and validated the Simulation of Tobacco and Nicotine Outcomes and Policy (STOP) model, a microsimulation of tobacco-related behaviors and clinical outcomes. Data from nationally-representative surveys are used for model inputs such as initial prevalence of never/former/current smoking, changes in smoking behaviors (initiation, cessation, and relapse), and the smoking-associated CVD risk.
In the current study, low SES was defined as having an income below the federal poverty level, having education less than high school, or being enrolled in Medicaid. SPD was defined as reporting a Kessler-6 score ≥13. People with both low SES and SPD were not separately modeled because of sparse data.
Smoking Increases CVD Risk More Than SPD or Low SES Does
The researchers first studied a hypothetical population of people who were initially 40 years old and whose tobacco smoking status (current or never) didn't change. The impact of smoking on 20-year cumulative CVD incidence was considerably larger than the impact of membership in a marginalized subpopulation:
- Difference in CVD incidence between current and never smokers: 11.6−13.5 percentage points for females, 14.9−16.5 for males
- Difference in CVD incidence between low SES smokers and higher SES smokers: 1.4 percentage points for females, 2.1 for males
- Difference in CVD incidence between SPD smokers and non-SPD smokers: 4.3 percentage points for females, 5.1 for males
Reducing Disparities in Smoking Would Reduce Disparities in CVD Risk
The team then studied hypothetical populations of individuals ages 20 to 85 (matching U.S. population data), including those with low SES or SPD, whose smoking status could change over time. In each year of the simulation, new 20-year-olds were added and some people died.
In the "status quo" scenario, death rates and decreases in current smoking prevalence were informed by NHIS data. In the "counterfactual" scenario, the smoking prevalence and trends for low SES and SPD populations were matched to those of higher SES and non-SPD populations.
The results of the counterfactual scenario showed reductions in the population's 20-year cumulative incidence of CVD relative to the status quo scenario:
- Low SES—6.2% reduction
- SPD—11.3% reduction
This translates to a projected 12,343 fewer CVD cases in the low SES population and 24,176 fewer in the SPD population.
Encouraging Tobacco Cessation Is Critical for Marginalized Populations
Reducing tobacco use in SPD and low SES populations could have relatively swift effects on tobacco-related CVD disparities. Changes in overall mortality risk develop over years to decades after smoking cessation, but CVD risk decreases more quickly.
The U.S. has set an "endgame" goal of <5% tobacco use prevalence, but that can't be attained without tailored interventions for marginalized subpopulations. Strategies could include reducing the density of tobacco retail shops in poor neighborhoods, expanding Medicaid coverage for tobacco treatment services, and improving tobacco cessation programs for people with mental illness.
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