Cessation as revolutionary—the morbid reality of tobacco-use disparities

I FIND IT FASCINATING that—despite my resolve and the temporal distance between me and my last cigarette—if I think about smoking enough I can still sense a subtle craving beneath the surface of my visceral consciousness. This craving coincides with memories, especially of long-gone relationships, all of which are swift and nostalgic in their transient retrospection.

These memory associations hint at nicotine’s subtle appropriation of nicotinic acetylcholine and dopaminergic neurotransmitters throughout the brain. While dopamine is generally thought of in simple notions of pleasure and reward, both the dopamine and acetylcholine systems assist in complex, subconscious learning processes, including memory formation, that reinforce behaviors conducive to survival. 1 2 3 Not only then do cigarettes produce pleasure (or alleviate the stress of addicted minds), but they imprint environmental stimuli onto the minds of their users, so that environmental cues and pleasurable memories imbue a former smoker such as myself with cravings. 4
 
But keep in mind, memories aren’t simply snap shots, some more or less fuzzy than others. Meaning and profundity, my very intimate notions of myself that shape my awareness and intelligence, my experiences that inform my social sensitivities and empathy—all of these things accompany my memories, and this is exactly what tobacco companies are taking advantage of through the commandeering of the dopamine system.
 
At any rate, the difficulty in quitting doesn’t come with the initial physical withdrawals but in the months and years ahead. This difficulty has to do with several nonpharmacological factors in addition to nicotine’s ability to strengthen memories (by connecting smoking’s positive dopamine releases with specific settings, people and experiences). 5 Broadly speaking, the extent that nonpharmacological factors contribute to tobacco’s use necessarily involves the social environment. Smoking’s prevalence, in other words, is a systemic, social issue.
 
I recognize that for some this is a problematic claim. Some say that, regardless of group concentrations, smoking’s prevalence “at the end of the day” is just a bunch of individuals freely making individual decisions. While people ought to take personal responsibility for their behaviors, thinking that one’s own smoking hadn’t been shaped by the biopsychosocial environment they were raised in, or that their own smoking doesn’t affect others, is a mistake. I get that even smokers might not see the utility in considering tobacco’s prevalence in their community or to what extent tobacco companies capitalize on their demographic; even so, without such influences, would tobacco still be the leading cause of premature death in the United States?
 
At some point in college, I realized the pattern of my smoking behavior—which lasted over a span of more or less seven years—had not been an anomaly. It had not been a coincidence that communities I had been a part of continue to smoke at high rates, despite smoking’s prevalence subsiding from the rest of the country. Be it tobacco’s sophisticated pharmacology, market profiling, or a tobacco-use identity shaped through generations, my behavior had been prototypical, another statistic, an issue of deadly morbidity and genealogical consequence. From within this framework, I came to realize that quitting, in and of itself, was a revolutionary thing to do.
 
 

The most profound realizations, about the consequences of one’s addiction, shrink against the fundamental reasons people cope with addictive behaviors in the first place.

 
 

 
 
I WONDER IF I NEVER LEFT THE ARMY would I still be smoking? Close to half (49.2%) of the entire U.S. military uses some form of tobacco, and about one-quarter (24%) smoke cigarettes, according a 2011 Department of Defense health survey. 6 Over one-third (38%) of people who join the military start smoking after enlistment, according to a 2016 memo signed by then Secretary of Defense Ashton Carter. 7 Another statistic, relevant to my experience, is that those who have deployed post 9/11 “are more often current and heavy cigarette smokers” compared to their never-deployed counterparts. 8
 
DOD’s 2011 research also surveyed a “perceived” “culture of substance use” (COSU): “When examining social network facilitation of substance use in the military, active duty personnel most often reported that peers engaged in alcohol use (89.0%), cigarette use (73.1%), and smokeless tobacco use (61.2%) in their off-duty hours.”
 
I served from 2008 to 2012. Thinking back on my active-duty time, these statistics reflect my own perception of tobacco use’s prevalence across the military—including my experience working with people from different military branches (and of different military forces, from Australians to Ugandans) throughout the U.S. and abroad.
 
What I perceived as the COSU at Camp Arifjan, Kuwait, and the life my squad lived conducting convoy security—traveling from one Iraqi FOB to the next—(somewhat) supports DOD’s findings about deployed soldiers having higher rates of smoking. The high mental health risk associated with deployment alone accounts for higher smoking rates among deployed personnel; the same can be said for being separated from friends and family. But in addition to those things was the vague sense that the “theater of operations” blurred usual militarily/culturally-enforced inhibitions.
 
For my unit, deployment was an agreement to face the possibility of death by an Improvised Explosive Device (IED), or Explosively Formed Penetrator (EFP), or to return deformed. It was also an agreement to abstain from alcohol, sex, and whatever else soldiers had access to stateside. The reason for these restrictions had something to do with not wanting to mess with “war preparedness”; however, the stimulating effects of abstinence had its obvious utility—a kind of weaponized sexual-frustration. Point being, the accumulative effect these things had on a soldier’s perspective, thus behavior, also encouraged its own COSU—which necessarily included smoking.

My impression of that particular COSU was that deployed soldiers (and officers) did everything they could to have sex, smuggle alcohol and get high. One of the soldiers, who had been smuggling vodka for months through the mail, mysteriously disappeared, which for about a week or so either entertained or disturbed soldiers. Sexual frustration got especially weird toward the end. Scandals and rumors were replete through the chain of command. The sex issue got so out of hand my unit’s senior non-commissioned officer (NCO) was awkwardly replaced mid-deployment after an alleged affair with one of his lower enlisted soldiers. Similarly awkward, he hung around, ensuring at least one unexpected run-in. Last I saw him, he had just walked out of an indoor hand-ball court. “Brother Graves,” he said. “Nice to see you.” His voice and normally cordial expression had marked undertones of humility. Whether out of an attempt to see the slightest indication of what his former soldiers thought of his conduct or that that had just been the first time we greeted each other without me being his soldier, I don’t know, but I recall what were once his soldiers barely holding themselves up straight in PT formation still high on dextromethorphan/oxycodone/paracetamol from the night before deliriously, kind of happily, swaying against the orange haze of Arifjan’s morning sky.
 
For those chronic smokers who deployed with us, they got their fix as often as they could. During long missions on the road, many used dip to hold themselves over. This meant inside some HUMVEE’s tiny compartment there’d be a brown sludge filled plastic bottle, which was sometimes next to another plastic bottle full of urine. Otherwise, for people like me, at the time an intermittent smoker, exotic forms of tobacco had their function in facilitating a temporary subculture within my unit. Shisha was used ritualistically in weekly gatherings myself and others could look forward to—especially during long stretches of down time. And traveling throughout Iraq, beedis were a cool novelty, good for smoking over blackjack. I even saved a victory Cuban cigar, bought at the Kuwait City airport, to celebrate not dying or accruing some kind of deformity; though, the thing had me throwing up after inhaling.
 
AT 22 YEARS OLD, I bought my first pack of Camel Crushes at a gas station in dreary upstate New York. Fort Drum had a particular reputation, known for its rapid deployment, lake-effect snow, isolation and suicide rate.
 
Isolation, as mentioned, tends to make people smoke. Not only did I desperately miss home, the relationships I had gained while at Fort Drum were as transient as any, and, when enough people I had connected with over cigarettes disappeared, social gatherings stopped being my sole cue for smoking.
 
 
 

 
 
 
At a small bar I’d frequent, it wasn’t the drinks or evasive women that brought me there but the connections I would otherwise lack with people if not for smoking. Even if no one else was standing on that ice in dry sub-zero temperatures, under that street light, outside the bar, the act of smoking carried with it the meaning of being with another.
 
 

 
 
At any rate, my dreary circumstance at Fort Drum doesn’t quite explain my behavior, or the behavior of soldiers in my unit or battalion, etc. After all, I entered the Army with what was called a “CLASSIC DOWNSCALE SMOKER” (CDS) background. CDS is a marketing classification found in a 1989 R.J. Reynolds corporate document, titled “MILITARY YAS INITIATIVE.” 9
 
A CDS background is some combination of “BLUE COLLAR”; “LESS-EDUCATED” (“HIGH SCHOOL” and “POOR ACADEMIC PERFORMANCE”); “LIMITED JOB PROSPECTS”; “PART OF ‘WRONG CROWD’”; and “IN TROUBLE WITH AUTHORITIES.” The author also draws parallels with RJR’s “CUSTOM MARKETING PROGRAMS” meant to “appeal” to YAS blacks and Hispanics.
 
The document equates civilian CDS consumers with the military and its largest demographic, Young Adult Smokers (YAS), ages 18-25, which are determined to be “KEY TO RJR’S LONG-TERM SUCCESS,” a “BIG OPPORTUNITY TO REACH YAS” and an “IMPORTANT OPPORTUNITY FOR RJR TO IMPROVE PERFORMANCE.” Out of detached business language, the RJR document profiles the interests, brand preferences, purchase patterns and value of the military’s YAS for more wide-spread capital gains, which the author calls “SPEED-AND-SPREAD.”
 
The RJR document draws conclusions from YAS soldiers’ lack of thrift and their preferences for convenience and “TOP QUALITY CIGARETTES,” noting that the most expensive brands, Marlboro and Camel, make up 78% and 80% of military market shares, respectively. YAS soldiers, the documents show, “AVOID COMMISSARY DUE TO LONG LINES EVEN THOUGH CIGARETTES PRICES MUCH LOWER [sic].” Similarly, these top-quality brand preferences evidence YAS solders’ want to “SEE THEMSELVES AS SUCESSFUL…[a] STEP ABOVE…WHAT THEY WERE [and] WHAT THEY WOULD HAVE BECOME”; [They] “WANT AND CAN AFFORD TOP QUALITY CIGARETTES—FULL PRICE BRANDS SEEN AS SUPERIOR QUALITY—SAVINGS BRANDS SEEN AS INFERIOR QUALITY”; and “SAVINGS BRANDS HAVE LIMITED POTENTIAL AMONG MILITARY YAS.”
 
The document also describes why Camel had done so well “AMONG WHITE MILITARY YAS.” Camel, according to the document, is “SEEN AS A PREMIUM QUALITY PRODUCT,” and its “ADVERTISING [is] CLEARLY PREFERRED OVER MARLBORO” because, similar to Marlboro, soldiers identify with Camel’s marketing mascot, or “IT’S CENTRAL HERO,” but, unlike Marlboro, Camel’s advertising is “MORE FUN,” has “SEXY WOMEN” and portrays a “WISEGUY PERSONALITY.”
 
In the document’s “SPEED-AND-SPREAD” bullet points, the author notes the military’s market value implications for the civilian market. Military YAS brand preferences “FORMED DURING MILITARY SERVICE” will “CARRY…BACK INTO THE CIVILAIN MARKET” either “WHILE HOME ON LEAVE” or “AFTER LEAVING MILITARY SERVICE.” Furthermore, the author points out how soldiers not only see themselves as leaders and successful, but they are “SEEN BY FRIENDS/FAMILY AS SUCCESSFUL.”
 
TODAY’S MILITARY CULTURE of smoking has an exhaustive, well-documented history, a lot of which implicates military collaboration with tobacco companies. Such is the case with how profits from tobacco products still fund Morale, Welfare, and Recreation (MWR) programs.10 11
 
As interesting as that is, what’s of interest here is what military personnel have in common with people of low socioeconomic status.
 
 

 
 
According to a 2014 Centers for Disease Control and Prevention (CDC) study, the low-socioeconomic-status (LSES) demographic, like the military, smokes cigarettes at higher rates compared to everyone else, despite steady declines of tobacco use since the 60s. 12 13 14 With that statistical difference and class divide comes a “higher lung cancer incidence” and, at least for civilians, being “diagnosed at later stages of diseases and conditions” because “lower-income populations have less access to health care.”
 
 

 
 
Although poverty-level income and low-educational achievement strongly correlate to higher smoking rates, education by far is the strongest variable in determining whether or not, or to what extent, someone smokes cigarettes. As seen in the graph above, adults with less than a high school education smoke at a rate three times that of adults with a college degree. A similar trend appears comparing the quitting behaviors on either side of these disparate lines. According to the CDC’s research, LSES people want to quit just as much as the general population, but LSES people are significantly less successful. Note the statistical significance between these two points:
 
“Adults who live below the poverty level have less success in quitting (34.5%) than those who live at or above the poverty level (57.5%)” [and] “Adults with less than a high school education (9–12 years, but no diploma) have less success in quitting (43.5%) than those with a college education or greater (73.9%).”
 
Several variables can account for the effect education appears to have on tobacco use. People who have an educated family background tend to live in areas with less smoking prevalence and tobacco industry marketing, so it’s difficult to argue that the college degree itself accounts for the smoking disparity between the general and LSES populations. Whether it’s getting a liberal arts education where they “teach you how to think” or years of assimilating within the social body of “higher education,” I can’t say for sure. There remains at least statistical evidence to account for differences I’ve observed as a high-school dropout, deployed soldier, and someone who quit smoking while finishing college.
 
ALTHOUGH I MYSELF HAD OBSERVED these trends, seeing that my experience reflects the larger picture (of who smokes and who doesn’t in the United States) confirms what I figured to be a systemic issue—disproportionately affecting my friends, family and community. Perhaps if they see how their smoking behavior works against their interest and undermines their community they would reconsider how they got to where they are and maybe change?
 
Merely being a part of a statistic doesn’t mean anything, however, unless people know what being a part of that stat entails. What I’m referring to of course are the health consequences of smoking cigarettes.
 
 

 
 
As an aside, however, a distinction needs to be made between tobacco and nicotine. As mentioned at the start of this composition, nicotine plays a sophisticated role in facilitating addiction; however, excluding nicotine, several known and unknown chemicals out of more than 7,000 in tobacco smoke have addictive properties. For example, a phenomenon of decreased levels of monoamine oxidase (MAO), which breaks down dopamine, has been observed with smoked tobacco and not with nicotine alone. Besides a difference in addictive pharmacology, nicotine is far safer than tobacco. Tobacco is the leading cause of premature death in the U.S., at about a half-million deaths a year. That’s “more than alcohol, illegal drug use, homicide, suicide, car accidents, and AIDS combined.” 15 Tobacco use–not nicotine alone–is what’s responsible for a host of diseases and cancers, foremost of which is lung cancer, “the number one cancer killer of both men and women.”
 
Still, even though nicotine is “not a complete carcinogen” and hasn’t been causally linked to tobacco-related diseases, to say nicotine doesn’t pose any risk whatsoever, simply isn’t true. According to a 2014 report from the surgeon general, there is some evidence that nicotine may promote tumor growth, though not necessarily the cause of tobacco-related cancers. 16 Apparently, there is only one study that “provides information about long-term users of NRT (Nicotine Replacement Therapy), which “does not indicate a strong role for nicotine in promoting carcinogenesis in humans, and clearly the risk, if any, is less than continued smoking.” In addition, nicotine use has a potential role in cardiovascular diseases, but these risks come with heavy, long-term use. Again, nicotine use doesn’t come without risks, but, unlike tobacco, if used responsibly and at appropriate doses, nicotine can be used as a relatively safe NRT. 17 At any rate, being maligned with tobacco, understandably, stifles nicotine’s perceived usefulness in facilitating smoking cessation.18
 
 

* * *

 
 
As a smoker, I never had an interest in understanding biology, let alone cancer. I more or less stumbled into curiosity about cancer via an introductory biology class. I never really considered or thought about biology, at all–which may explain why thinking about germline mutations became the little nugget of reality that motivated me to quit. 19 The other aspect of my motive came out of anger for smoking’s prevalence in my community (having also observed that my folks smoked more than the people in other places I frequented). It’s been years since I quit, but this adversarial relationship with cigarettes has been sustaining my abstinence.
 
Both smoking and nonsmoking readers may not be aware of how tobacco’s carcinogens interact with DNA; therefore, a brief breakdown of its mechanisms is necessary.
 
The carcinogens in tobacco are mutagens, an external mutation-producing chemical, causing DNA mutations outside the normal rate of mutations. 20 Mutations occur naturally but infrequently, over long periods of time, which is why cancer would otherwise be a disease associated with older folks. To account for this natural degradation, cells will self-destruct (called apoptosis) to rid the body of these unwanted cells. Carcinogens disrupt the cell cycle, including apoptosis, essentially modifying the instruction manual that DNA stores for cell replication. When carcinogenically-modified cells replicate, they skip the DNA proof reading, and mistake correcting, and go straight to dividing these compromised cells, at an accelerated rate, causing tumors that can release more of these cells into the blood stream, causing tumors elsewhere in the body, like the lungs, mouth, myeloid blood cells, et al. The horrid sounding term for this process is called carcinogenesis, commonly called cancer.
 
 

 
 
Much of the attention concerning tobacco’s health hazards has focused on the individual (this isn’t necessarily a point about the media but more of a reminder of how people tend to think in heuristic and localized-experience terms). Second-hand smoke is an example of cigarette’s health hazards extending beyond the individual, but such consequences can be mitigated by so-called responsible smokers. Nevertheless, whether tooth decay, bronchitis, or cancer, the risks imbued in tobacco use have seemingly been left with the lone individual to contend with. Paradoxically, some use this reason to justify their tobacco use to themselves and others.
 
Regrettably, however, tobacco’s carcinogens move the health consequences beyond just the individual. Tobacco’s cancer-causing properties have genealogical ramifications.21 They don’t just affect somatic cells (body cells) but also mutate germline cells (cells for procreating). Even if smoking didn’t give me cancer, smoking will at least increase the risk of my children–or my friends’ children–getting cancer.
 
PERHAPS THEN, WHAT PUSHED ME in the direction of cessation was reason. That’s not to discount the evil hold addiction can have on people. In the case of terminally addicted minds, the most profound realizations, about the consequences of one’s addiction, shrink against the fundamental reasons people cope with addictive behaviors in the first place, so showing people that they’re working against their interest, or that of the people they love, doesn’t always seem an effective way of promoting change. There’s also the issue of thinking of addiction in relative terms, which doesn’t come without merit. After all, addiction does occur on a spectrum, each addict particularly entrenched within a biopsychosocial scale of severity, from workaholic doctors to schizophrenic hospice patients succumbing to comorbidity from decades of intravenous cocaine injection. 22 There is wisdom to such intuitions about moderation. But because of tobacco’s genetic mutating potential, thinking of one’s tobacco use in relative terms is problematic in ways other behaviors are not.
 
Indeed, beyond my experience, reason appears to have very little to do with helping people quit life-threatening addictions. As grim as it feels to come to terms with this—America’s most vulnerable populations have had their identities imbued with the marketing schemes of cigarette companies. With sophisticated appeals to the material insecurities of the have-nots—like an Edward Bernays wet dream—smoking looks counter-revolutionary in the trenches of America’s stratified society.23
 
 
Photos by Nolan Ryan Trowe
 
 

  1. Addiction Becomes a Brain Disease
  2. Nicotine creates stronger memories, cues to drug use
  3. Why Your Brain Craves Cigarettes When You Drink
  4. μ-Opioid Receptor and CREB Activation Are Required for Nicotine Reward
  5. Complex interactions between nicotine and nonpharmacological stimuli reveal multiple roles for nicotine in reinforcement
  6. 2011 Department of Defense Health Related Behaviors Survey of Active Duty Military Personnel
  7. Policy Memorandum 16-001, Department of Defense Tobacco Policy
  8. Tobacco Use and the Military
  9. MILITARY YAS INITIATIVE
  10. Tobacco Promotion to Military Personnel: “The Plums Are Here to Be Plucked”
  11. The discount that links big tobacco to the military
  12. CDC – Tobacco-Related Disparities – People of Low Socioeconomic Status and Tobacco Use
  13. America’s new tobacco crisis: The rich stopped smoking, the poor didn’t – The Washington Post
  14. Patterns of Tobacco Use Among U.S. Youth, Young Adults, and Adults—The Health Consequences of Smoking—50 Years of Progress
  15. National Institute on Drug Abuse Tobacco Research Report Series
  16. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014; Health Consequences of Nicotine Exposure; pages 113-126
  17. In an earlier version of this article, an article from thelancet.com–which called for evidence-based studies on the health consequences of e-cigarettes–had been used to supplement this claim. While NRT is a viable and safe tool for people who are trying to quit their tobacco use, a recent study out of the Johns Hopkins Bloomberg School of Public Health showed high levels of mutagenic and neuro-toxic metals in the tanks and aerosol from e-cigarettes.
  18. The Drug Classroom–Nicotine
  19. Mainstream Tobacco Smoke Causes Paternal Germ-Line DNA Mutation
  20. The Cell Cycle and Cancer
  21. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014; Mechanisms of Cancer Induction by Tobacco Smoke; pages 148-51
  22. In the realm of hungry ghosts close encounters with addiction Gabor Maté-Peter Levine – North Atlantic Books – 2010
  23. New Human Rights Movement, The: Reinventing the Economy to End Oppression – Chapter Two – page 35 – Peter Joseph – BenBella Books – 2017

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