After decades of lawsuits, public campaigns and painful struggles, Americans have finally done what once seemed impossible: Most of the country has quit smoking, saving millions of lives and leading to massive reductions in cancer.
That is, unless those Americans are poor, uneducated or live in a rural area.
Hidden among the steady declines in recent years is the stark reality that cigarettes are becoming a habit of the poor. The national smoking rate has fallen to historic lows, with just 15 percent of adults still smoking. But the socioeconomic gap has never been bigger.
Among the nation's less-educated people - those with a high-school-equivalency diploma - the smoking rate remains more than 40 percent, according to the Centers for Disease Control and Prevention. Today, rural residents are diagnosed with lung cancer at rates 18 to 20 percent above those of city dwellers. By nearly every statistical measure, researchers say, America's lower class now smokes more and dies more from cigarettes than other Americans.
This widening gap between classes carries huge health implications and is already reshaping the country's battle over tobacco control. Cigarette companies are focusing their marketing on lower socioeconomic communities to retain their customer base, researchers say. Nonprofitand advocacy groups are retooling their programs for the complex and more difficult work of reaching and treating marginalized groups.
As inequality in America continues expanding by many measures, smoking is a growing aspect of that divide that is a matter of life and death, with wealthier and more-educated Americans now largely spared the cost and deadly effects of the vice.
Advocacy groups say funding for smoking cessation is dropping, and they worry the attention and political will needed for tobacco control is also waning as America's upper and middle classes see smoking as an already solved, bygone problem.
"If you're educated and live in a well-off area, the smoking problem we're talking about these days is now largely invisible to you," said Matthew Myers, president of the Campaign for Tobacco-Free Kids. "In some places, you can go days without bumping into a smoker. So you start to hear the question, why push more resources into this? Meanwhile, the need is getting even greater, because the people left smoking are the ones who can least afford to."
Smoking a symptom of deeper problems
Debbie Seals, 60, has fought on the front lines of this new class battle for the past six years from her home in the rural foothills of Virginia's Blue Ridge Mountains.
She has driven her tiny blue Fiat to the farthest corners of southern Virginia and West Virginia to hold classes aimed at helping smokers quit. Her cessation clinics are often the only ones offered for miles around.
"It's like there's two worlds now," Seals said.
(Smoking is) the one thing they have control over. The one thing that makes them feel better. And you want them to give that up? It's the toughest thing in the world.
Debbie Seals, smoking cessation teacher
Every month, she travels to Northern Virginia to visit her grandchildren in the D.C. suburbs. In Alexandria, she sees couples jogging on the streets and buying expensive organic groceries at Whole Foods - and not a single one smoking.
But in her home town of Martinsville, Va., cigarettes are ubiquitous. People smoke on their morning drive to work and on weekends mowing their lawns. Tobacco stores line the strip malls, and cigarette ads are in the windows of every gas station and convenience store.
The smoking is a symptom of deeper problems here, Seals said on a recent afternoon as she headed out to check on three former students from her cessation class.
Martinsville was once known as the "Sweatshirt Capital of the World," a booming center of textile mills and furniture factories. Now it is littered with abandoned factories and vacant storefronts. So many families here live in poverty that all children in elementary and middle school automatically qualify for free and reduced-price meals.
"People down here smoke because of the stress in their life," Seals said. "They smoke because of money problems, family problems. It's the one thing they have control over. The one thing that makes them feel better. And you want them to give that up? It's the toughest thing in the world."
Seals - who retired years ago from a career with Girl Scouts of the USA - began teaching her classes as a volunteer for the American Lung Association. After seeing the desperate need, she began working full time on cessation for the nonprofit.
If they manage to quit for a week or even a day, they succeeded. I tell them if you were able to quit once, you can do it again.
She's taught many classes in recent years at the handful of furniture factories left. Many of the participants attend her clinic over and over, unable to stop smoking. She is careful not to make any of them feel like failures.
"If they manage to quit for a week or even a day, they succeeded," she said. "I tell them if you were able to quit once, you can do it again."
Meeting up with three of her former students at a diner last week, Seals probed gently, asking how much they are smoking these days.
"I've slid back," admitted Victoria Cassell, 57, who has attended Seals's seven-week program every year for four years. "There was just too much going on in my life last year."
First, Cassell's sister died. Then her husband started having heart problems again. On top of it all, her daughter and grandson moved back in.
The last time Cassell tried to quit was three months ago, after a doctor's test gave her a lung cancer scare. "It was like losing my best friend," she said. "My cigarettes have kept me company for 40 years, longer than just about anyone in my life."
She ate lunch alone at the factory where she works, because her friends all smoke. She tried coloring while watching TV, just to keep her hands busy.
Three days in, an argument with a co-worker pushed her over the edge, she said. She ran to a friend at her first chance to bum a cigarette.
Pulling out her pack of Winstons, she tried to describe the feeling of that first cigarette after a hiatus. "It makes you feel like you're floating," she said. "You get lightheaded like you could just lay down and sleep. It almost gets you a little bit drunk."
Seals, sitting nearby, said: "I'm proud of you for holding out as long as you did."
Tobacco companies work to retain their customers
It wasn't always this way.
When smoking first gained popularity in the early 20th century, it was a habit of the rich, a token of luxury dusted with Hollywood glamour. Then came the 1964 surgeon general's report on its deadly effects, and during the next 3 1/2 decades, smoking among the nation's highest-income families plummeted by 62 percent. But among families of the lowest income, it decreased by just 9 percent.
"There's this tendency now to blame the ones still smoking," said Robin Koval, president of Truth Initiative, a leading tobacco-control nonprofit group. "The attitude is, 'You're doing it to yourself. If you were just strong enough, you'd be able to quit.' "
What isn't taken into account, Koval said, are the vast resources tobacco companies are spending to hold onto their last remaining strongholds.
In recent years, studies have found those companies' discounts often target low-income and minority communities. New research also shows that lower-income neighborhoods have a much higher density of tobacco retailers.
"Poorer people don't smoke because anything's different or wrong about them," Koval said. "Their communities are not protected like others are. They don't have access to good health care and cessation programs. If you have a bull's eye painted on your back, it's harder to get away."
Tobacco companies have also invested considerable resources in recent years lobbying against smoking restrictions and taxes, especially in poorer, rural and often southern states, where smoking remains highest.
Several major tobacco companies did not respond to requests for comment on the socioeconomic disparities related to the use of their products. The country's largest tobacco company - Altria, based in Richmond - said it uses the same marketing approach across rural, suburban and urban retail locations and makes sure its signage follows legal limits.
Altria spokesman George Parman also pointed to more than $112 billion that tobacco companies have handed over for smoking prevention as part of the 1998 Tobacco Master Settlement Agreement. Parman said that it has been state lawmakers across the country who keep diverting those massive funds to other budgetary needs, leaving just a fraction for anti-tobacco programs.
Even that funding is now shrinking, and nonprofits and health agencies have begun revamping their approach to fit the new socioeconomic trend. This winter, the Truth Initiative launched a series of ads framing tobacco companies' targeting of black and low-income neighborhoods as a social-justice issue. "It's not a coincidence. It's profiling," the ads say.
The CDC has used a national ad campaign of its own to reach especially hard-hit populations, including low-income, rural, Native American, mentally ill and minority smokers.
In the tobacco control world, "disparity" and "health equity" have become new catchwords, and pilot programs in some states have been launched.
"But the frustrating thing for folks in the public-health community is we know from research exactly what would make the biggest difference," said Brian King, deputy director for the CDC's Office on Smoking and Health. "They're just not being implemented at the policy level. It's bread-and-butter strategies like getting states to pass smoke-free laws, increasing cigarette taxes and funding tobacco cessation and prevention."
In the face of such frustrations and challenges, Seals - the cessation teacher in Martinsville - said she tries relentlessly to keep herself and her students focused on the positive.
"They need someone who will come in and say, 'It's okay, you're going to be able to stop,' " she said.
As Seals's visit with her former students came to a close, Cassell - the factory worker who has now tried quitting six times - said she measures her victories these days in smaller increments: cutting back to a pack every three days, holding out until after her morning cup of coffee to light up.
"Do I ever think I'll be able to quit?" she said. "No."
Seals responded with a smile, unfazed. "Well, are you going to be at the next clinic?"
"I'll be there," Cassell promised. "I don't know if it's ever going to take, but I'll keep trying."