Christine Sheffer, associate medical professor at CCNY's Sophie Davis School of Biomedical Education, tracked smokers from different socioeconomic backgrounds after they had completed a statewide smoking cessation program in Arkansas.

Whether rich or poor, participants managed to quit at about the same rate upon completing a program of cognitive behavioral therapy, either with or without nicotine patches. But as time went on, a disparity between the groups appeared and widened.

Those with the fewest social and financial resources had the hardest time staving off cravings over the long run. "The poorer they are, the worse it gets," said Professor Sheffer, who directed the program and was an assistant professor with the University of Arkansas for Medical Sciences at the time.

She found that smokers on the lowest rungs of the socioeconomic ladder were 55 percent more likely than those at the upper end to start smoking again three months after treatment. By six months post-quitting, the probability of their going back to cigarettes jumped to two-and-a-half times that of the more affluent smokers. The research will be published in the March 2012 issue of the "American Journal of Public Health" and will appear ahead-of-print online under the journal's "First Look" section.

In their study, Professor Sheffer and her colleagues noted that overall, Americans with household incomes of $15,000 or less smoke at nearly three times the rate of those with incomes of $50,000 or greater. The consequences are bleak. "Smoking is still the greatest cause of preventable death and disease in the United States today," noted Professor Sheffer. "And it's a growing problem in developing countries."

Harder to Stay Away

Professor Sheffer suggested reasons it may be harder for some to give up tobacco forever.

Smoking relieves stress for those fighting nicotine addiction, so it is life's difficulties that often make them reach for the cigarette pack again. Unfortunately, those on the lower end of the socioeconomic scale suffer more hardships than those at the top -- in the form of financial difficulties, discrimination, and job insecurity, to name a few. And for those smokers who started as teenagers, they may have never learned other ways to manage stress, said Professor Sheffer.

For people with lower socioeconomic status (SES), it can be tougher to avoid temptation as well. "Lower SES groups, with lower paying jobs, aren't as protected by smoke-free laws," said Sheffer, so individuals who have quit can find themselves back at work and surrounded by smokers. Also fewer of them have no-smoking policies in their homes.

These factors are rarely addressed in standard treatment programs. "The evidence-based treatments that are around have been developed for middle-class patients," Professor Sheffer pointed out. "So (in therapy) we talk about middle-class problems."

Further research would help determine how the standard six sessions of therapy might be altered or augmented to help. "Our next plan is to take the results of this and other studies and apply what we learned to revise the approach, in order to better meet the needs of poor folks," she said. "Maybe there is a better arrangement, like giving 'booster sessions'. Not everybody can predict in six weeks all the stresses they will have later on down the road."

"Some people say [quitting] is the most difficult thing in their life to do," said Sheffer. "If we better prepare people with more limited resources to manage the types of stress they have in their lives, we'd get better results. "

The research was funded by National Institutes of Health National Cancer Institute (R03 CA141995-01A1) and the National Center for Research Resources (RR 020146). The treatment program was funded by the Arkansas Department of Health.

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