In recent decades, air quality has improved in the United States, smoking rates have plummeted and government safety regulations have reduced exposure to workplace pollutants. But rich and poor Americans have not benefited equally, scientists reported in a paper on Friday.
While wealthier Americans have quit smoking in droves, tobacco use remains frequent among the poor. Asthma has become more prevalent among all children, but it has increased more drastically in low-income communities. And poor Americans continue to have more chronic lung disease than the wealthy.
Even when scientists controlled for the ill health effects of higher smoking rates among low-income individuals, they found the respiratory health gap persisted between rich Americans and people from poor communities.
“Over all, air quality has improved over the past six decades, but the fruits of that improvement have not been equitably enjoyed in our society,” said Dr. Adam Gaffney, an assistant professor at Harvard Medical School and lead author of the paper. “The disparities in lung health that were present in the 1960s have persisted and, in some cases, even widened.”
The Covid-19 pandemic, which has taken a disproportionate toll on people of color in the United States, has shone a light on the stark racial health gap in America. Black, Hispanic and Native Americans and Alaska Natives have become infected with the coronavirus at higher rates than white Americans; they have been hospitalized about three times more often, and they have died at about twice the rate of white Americans.
Some of these disparities may be explained by occupational exposures, crowded housing, difficulties gaining access to health care and higher rates of pre-existing health conditions, like diabetes. But the new study also suggests that poor lung health and higher rates of respiratory problems may have left lower-income Americans susceptible to the pneumonia often caused by the coronavirus.
The analysis, which was published in JAMA Internal Medicine, included data from national health surveys conducted by the Centers for Disease Control and Prevention periodically from 1959 to 2018. The study did not examine disparities in respiratory health by race or ethnicity, though it assessed both income-based and education-based differences in lung health.
The surveys, which use nationally representative samples of the population, asked people about respiratory problems, including lung diseases, symptoms like shortness of breath, wheezing and coughing, and whether they smoked or used to smoke. Though much of the information was self-reported, some respondents were also given tests of lung function.
Before the 1980s, smoking rates didn’t vary much by income, and they only slightly varied by education level: 62 percent of the wealthiest adults and 56 percent of the poorest were either current or former smokers.
But that has changed drastically. By the survey period 2017-18, current and former smoking rates among the wealthiest dropped by nearly half to 34 percent — while rates among the poorest inched up to 57.9 percent
Though smoking is an acquired habit, lower-income people may be more likely to use tobacco to cope with the stresses of poverty, Dr. Gaffney said. Tobacco advertising often targets low-income communities, and there is a higher density of tobacco stores in poor neighborhoods, according to the authors of a commentary accompanying the study. Poor people may also have more limited access to smoking cessation programs and replacement therapies, they said.
“We’re increasingly thinking of tobacco dependence as a disease,” said Dr. Sarath Raju, an assistant professor of pulmonary and critical care medicine at Johns Hopkins University and one of the authors of the commentary. “Individual responsibility is important, but without appropriate treatment or access to treatment to help you quit, that’s a challenge.”
Among children, asthma rates increased in all income groups after 1980, but they rose more sharply among children from poorer households. There was little difference in asthma rates in young children aged 6 to 11 before 1980, which stood at 3 percent to 4 percent. But by 2017-18, rates among the poor increased to 14.8 percent, compared with 6.8 percent among children from the highest income families. (A similar pattern emerged among adults; statistical adjustments for smoking only slightly reduced the differences.)
Among low-income adults, rates of chronic obstructive pulmonary disease, an inflammatory lung disease, have long been higher than among wealthier individuals. But rates have increased, widening the gap, with prevalence among the poorest Americans increasing to 16.3 percent from 10.4 percent, even as the rate remained stable, at 4.4 percent, among the wealthiest.
Between 1959 and 2019, poorer and less-educated adults consistently reported more troubling respiratory symptoms, like labored breathing, than wealthier, more educated people. For some symptoms, like having a problem cough, the gap between the rich and poor widened over time.
Wheezing rates fell for the highest income and most educated groups, but they remained stable in the poor, least educated groups, the study found.
The authors blame numerous factors for the disparities, including air pollution, workplace exposures, lung infections, prenatal exposures, premature birth and nutritional deficiencies.
“Air quality varies a lot, not just from one city to another city, but also neighborhood by neighborhood and even block by block,” said Dr. Steffie Woolhandler, the paper’s senior author, a primary care physician and a professor of public health and health policy in the CUNY School of Public Health at Hunter College.
“An affluent person would probably not choose to live near a highway because there is diesel exhaust and car exhaust, and would choose not to live near a factory or power plant,” she said. “A poor person doesn’t necessarily have that choice.”
The same is true for jobs, said Dr. Woolhandler, a founder of Physicians for a National Health Program, which advocates expanded health coverage through a single-payer health plan.
“If you have choices about what jobs you take, you’re not going to work in a smoke-filled environment or an environment full of fumes, whereas people who don’t have choices do have to work in those environments,” she said.
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