Current or Former Smokers Low Income Smokers at Risk for Greater Burden of Tobacco-Related Health Outcomes Theresa Juster MPH, Francis Boscoe PhD, Harlan Juster PhD Background Disparities in current smoking by income and other measures of socioeconomic status (SES) have been well established among adults in the US. Adults living below the federal poverty level (low SES) experience significantly higher rates of current smoking compared to adults living at or above the poverty level (high SES). Rates of smoking prevalence over time have decreased faster among higher SES adults compared to low SES adults. Results Table 1. Demographic Characteristics of Current or Former Smokers by Income Status NYS BRFSS 2012 Table 2. Prevalence of Chronic Disease by Income and Smoking Status NYS BRFSS 2012 Table 3. Logistic Regression with Interaction   Current or Former Smokers Low Income High Income % 95%CI Current smoker 53.1 [47.6,58.5] 31.7 [28.5,34.9] Former smoker 46.9 [41.5,52.4] 68.3 [65.1,71.5] Male 59.0 [54.0,64.1] 55.9 [52.8,59.1] 18-40 yrs 38.9 [33.3,44.5] 28.4 [25.2,31.6] Married 19.4 [15.3,23.5] [52.6,59.1] Employed 31.3 [26.0,36.7] 66.3 [63.3,69.3] <=HS education only 68.9 [64.4,73.4] 35.9 [32.6,39.2] Poor mental health 23.7 [18.8,28.7] 11.5 [9.3,13.6] Disabled* 43.8 [38.6,49.0] 19.6 [17.1,22.2] *Limited due to physical, mental, or emotional problems, or required to use special equipment (cane, wheelchair, special bed or telephone.) Private health insurance 18.0 [13.7,22.2] 69.8 [66.6,72.9] Medicaid 26.7 [21.2,32.2] 1.9 [0.8,2.9] Medicare 22.9 [18.7,27.2] 14.2 [12.2,16.1] No health insurance 18.1 [12.7,23.6] 4.7 [3.0,6.4] NYS BRFSS 2012   Current or Former Smoker Never Smoker Low Income High Income % 95%CI X² Heart Attack 11.3 [7.8,14.7] 3.9 [2.9,4.9] <.0001 2.8 [1.7,3.9] 2.0 [1.1,3.0] 0.3220 Stroke 8.1 [4.8,11.4] 1.2 [0.7,1.7] 2.4 [1.3,3.5] 1.8 [1.0,2.7] 0.6588 Diabetes 15.4 [11.8,19.0] 9.1 [7.4,10.7] 0.0009 11.9 [9.0,14.8] 7.0 [5.1,8.8] 0.0045 COPD 19.4 [15.2,23.6] 8.0 [6.4,9.6] 3.2 [2.0,4.4] 2.5 [1.3,3.7] 0.4543 CHD [6.7,11.6] 4.9 [3.8,6.1] 0.0007 4.7 [2.2,7.2] 3.1 [1.8,4.5] 0.2360 Arthritis 36.4 [31.5,41.4] 29.7 [26.8,32.6] 0.0190 22.6 [18.7,26.5] 18.8 [16.5,21.2] 0.0993 Kidney Disease 2.9 [1.3,4.4] 1.3 [0.7,1.9] 0.0322 [1.2,4.3] 2.2 [1.0,3.3] 0.5442 Skin Cancer 2.7 [1.6,3.9] 5.5 [4.2,6.7] 0.0032 [1.0,2.5] 3.5 [2.6,4.3] 0.0078 Other Cancers 7.5 [5.2,9.8] 8.7 [7.1,10.4] 0.3987 4.4 [2.6,6.2] 5.1 [3.9,6.3] 0.5337 Asthma 26.7 [21.4,32.0] 12.6 [10.5,14.7] 11.2 [8.4,14.0] 11.4 [9.4,13.4] 0.9019   p OR Heart Attack 0.0326 2.3 Stroke 0.0003 5.3 Diabetes 0.9576 COPD 0.0337 2.2 CHD 0.5815 Arthritis 0.6857 Kidney Disease 0.3180 Skin Cancer 0.9519 Other Cancers 0.9664 Asthma 0.0001 2.6 Study Objective To evaluate the impact of smoking by income status on tobacco related health outcomes for residents of New York State (NYS) using data from the NYS BRFSS and NYS Cancer Registry. Methods NYS lung cancer incidence cases were obtained from the NYS Cancer Registry November 2015 for diagnosis years 2000, 2009, 2012 and 2013. Cases were geocoded to census tracts based on address at time of diagnosis. Data were merged with poverty level files obtained from the U.S. Census Bureau by year and census tract. Cancer cases were assigned a poverty category of ‘Low’ for cases with census tracts that had less than 5% households below poverty level, or ‘High’ for cases with census tracts with greater than or equal to 20% households below the poverty level. Age-adjusted rates were then calculated using the direct method. Separately, prevalence of current smoking by individual income (<$25,000 vs >=$25,000) was measured from the 1985-2014 NYS BRFSS data files. Prevalence of heart attack, stroke, diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), arthritis, kidney disease, skin cancer, other cancers, and asthma by tobacco use and income (<$25,000 vs >= $25,000) were analyzed from the 2012 NYS BRFSS. Logistic regression and chi-square analysis was conducted using SAS 9.4. The interaction of smoking status and income on health outcomes was also tested. Fig.1 Incidence of Lung Cancer by Poverty Status NYS 2000-2013 Fig.2 Prevalence of Current Smoking by Income NYS BRFSS 1985-2014 Fig.3 Prevalence of Heart Attack By Income and Smoking Status NYS BRFSS 2012 Fig.4 Prevalence of Stroke By Income and Smoking Status NYS BRFSS 2012 References Boscoe FP, Johnson CJ, Sherman RL, et al. The Relationship Between Area Poverty Rate and Site- Specific Cancer Incidence in the United States. Cancer. 2014 Jul 15;120(14): 2191-2198. Clegg LX, Reishman ME, Miller BA, et al. Impact of Socioeconomic Status on Cancer Incidence and Stage at Diagnosis: Selected Findings from the Surveillance, Epidemiology, and End Results: National Longitudinal Mortality Study. Cancer Causes & Control 2009 May; 20(4): 417-435. Jamal A, Homa DM, O’Connor E, Babb SD, Caraballo RS, Singh T, Hu SS, King BA. Current Cigarette Smoking Among Adults – United States, 2005-2014. MMWR Morb. Mortal Wkly Rep 2015; 64: 1233-1240. Vidrine JI, Reitzel LR, Wetter DW. Tobacco’s Role in Cancer Health Disparities. Curr Oncol Rep. 2009 Nov; 11(6): 475-481. Findings A greater proportion of low income smokers are single, unemployed, have less than a high school education, have poor mental health, are disabled, and have public insurance compared to smokers with high income (Table 1). The rate of current smoking among low income adults is significantly higher compared to high income adults (Fig. 2). Low income populations experience greater lung cancer incidence compared to high income populations with a disproportionally slower change in rate over time (Fig 1). Significantly higher prevalence of tobacco-related chronic diseases exist among smokers with low incomes compared to those with high incomes (Table 2, Fig. 3 & 4). A significant interaction between income and smoking exists when evaluating the prevalence of heart attack, stroke, COPD and asthma; disease rates are highest among low income smokers compared with high income smokers and never-smokers (Table 3, Fig. 3 & 4). Conclusions Low income smokers carry a greater burden of tobacco-related chronic diseases compared with never smokers and high income smokers. Differential access to health care, lifestyle and rate of tobacco consumption could account for the greater burden of disease among low income smokers compared with high income smokers. Attention to reducing smoking within this vulnerable population is vital.