1.10 Prevalence of smoking in other high risk sub-groups of the population

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Discussion of general trends in smoking prevalence in Australia overlooks population sub-groups which may have much higher smoking rates, or for whom smoking causes special problems. Individuals with lower socioeconomic status or lower educational attainment are more likely to smoke, as discussed in Section 1.7. Aboriginal peoples and Torres Straits Islanders, discussed in the preceding section and in detail in Chapter 8, also show substantially higher smoking rates than the rest of the population, as do members of some other culturally and linguistically diverse communities (Section 1.8). Following is brief discussion about other population groups among whom smoking prevalence is either higher than overall Australian prevalence, or for whom smoking poses greater than usual health risks.

1.10.1 Smoking in pregnancy

Smoking patterns in pregnancy are of particular importance since tobacco use harms the unborn child as well as the pregnant woman.83

The Australian Institute for Health and Welfare's National Perinatal Data Unit (NPDU) reports data on births in Australia. It collects information concerning both the mother (including demographic profile and matters relating to the pregnancy and birth) and the baby (such as sex, birthweight and other health indicators).84[9]

The NPDU reports that in 2005, 17.4% of women smoked during pregnancy84 (Table 1.10), down marginally from 19.2% in 2001.85 There was considerable variation between states, probably in part due to different means of ascertaining smoking status (see notes to Table 1.10). Lowest smoking rates of about 14% were recorded in New South Wales and the ACT, and the highest recorded prevalence of smoking in pregnancy was reported for the Northern Territory (31%). The NDSHS (2004) found that 20% of women who were pregnant or breastfeeding continued to smoke,43 down from 23% in 2001.86

As well as regional variations noted in Table 1.10, there are also variations in the prevalence of smoking during pregnancy in certain sub-populations, presumably reflecting smoking behaviour in these groups within the wider population. For example women who were most disadvantaged were more than four times more likely to smoke than women who were least disadvantaged (28% compared to 6%). Women with Aboriginal or Torres Strait Islander backgrounds were more than three times more likely to smoke during pregnancy than non-Indigenous women (53% compared with 16%). Likelihood of smoking during pregnancy decreased with maternal age. Forty-two percent of teenagers smoked during pregnancy.85

Other research has shown that women without a partner, the less educated,87 those with lower socioeconomic status87, 88 and women with a psychiatric disorder89 are more likely to smoke during pregnancy.

The Australian National Tobacco Strategy 2004–2009 has identified expectant
and new parents as a priority target group for future education and cessation support interventions.90 The health consequences of smoking and exposure to second-hand smoke during pregnancy are discussed in Chapters 3 and 4 respectively. For information on issues related to quitting smoking during pregnancy, refer to Chapter 7.

1.10.2 Smoking and mental illness

Mental health problems are common within the Australian population, with one in ten Australians (children and adults) reporting a long-term mental or behavioural issue.14 Mental health problems include both mild and occasional problems as well as more debilitating conditions such as major depression and very serious psychotic illnesses such as bipolar disorder and schizophrenia, characterised by fundamental distortions of thinking, perception and emotional response.91 Individuals with mental health conditions have a higher prevalence of smoking and those who smoke tend to smoke more heavily than the general population.91-93 Higher rates are observed in those with severe mental illness than in those with milder mental health problems and highest rates are observed among those with a diagnosis of psychosis.93 Australian research has reported smoking rates of up to 35% among patients suffering from common mental disorders14, 94 (defined as affective, anxiety or substance use). An international meta-analysis of studies on smoking among people with schizophrenia reported pooled prevalence of 60%. An Australian study found rates of 73% in men and 56% in women suffering from psychotic illnesses such as schizophrenia.91 Among mentally ill in-patients with co-existing alcohol and other drug problems, smoking rates as high as 90% have been observed.95 People with mental health illnesses who live in institutions have higher rates of smoking than those living in the community.93

These excessive smoking rates contribute to higher levels of tobacco-caused morbidity and mortality among the mentally ill.96

Smokers living with mental illness are severely disadvantaged both by their illness and by expenditure of limited resources on tobacco products—see Chapter 9 for further discussion. Smokers who suffer from severe mental health illnesses, and those living in institutions, have been identified in the Australian National Tobacco Strategy90 as requiring specialised strategies to assist in cessation. For further discussion on cessation in this target group, see Chapter 7.

1.10.3 Lone parents

In Australia between 2004 and 2006, 22% of all family groups were led by a lone parent, and on average, one in five children aged less than 15 was being cared for in a family with one parent.97 Eighty-seven percent of lone parents bringing up children aged under 15 are women.97

Australian research has found that the overall prevalence of smoking among lone mothers is about 46%, with those younger in age (18–29 years) reporting the highest prevalence (59%).98

Lone parenthood is associated with social and economic disadvantage,97 and is discussed further in Chapter 9.

1.10.4 The homeless

Homelessness is defined as lacking adequate access to safe and secure housing. The 2001 Australian National Census showed that there are about 100,000 homeless people in Australia.99

Individuals experiencing homelessness have a poorer health status than the general population, with the "street homeless" (those usually dwelling on streets or in parks, in derelict buildings or other temporary shelters) being the worst affected.100 Melbourne-based research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%.100 For further discussion refer to Chapter 9.

1.10.5 The prison population

The prevalence of smoking in the prison population is far higher than among the general population,101, 102 and tobacco use is commonly accepted as part of prison life.102 It is not unusual for tobacco to be used as currency in gambling or other trade.102

Research undertaken in 2001 examining smoking in New South Wales prisons found that 78% of male and 83% of female inmates were smokers.102 Most (95%) inmates smoked RYO cigarettes, a far higher proportion than that seen in the rest of the population; and possibly an indicator of a greater degree of addictedness as well.102 Forty-one percent of prisoners who smoked reported that they smoked more heavily in prison than when in the community. Illicit drug use was closely connected to tobacco use, with about 90% of individuals who had ever injected drugs, or used cannabis, being smokers as well.102 Eighty-six percent of inmates aged under 25 were smokers, compared to 64% of prisoners aged over 40. Prisoners who smoked were less likely to have completed their schooling. A small number of smokers had started smoking in prison (7%).102

The elevated smoking rates in the prison population reflect, to a large extent, increased likelihood of disadvantaged socioeconomic backgrounds in inmates. Indigenous people, drug users, and the less educated are over-represented in the prison system, as are those suffering mental illness.102, 103 As noted elsewhere in this chapter, each of these factors predicts higher smoking rates.

The Australian National Tobacco Strategy90 has identified the prison population as a priority area for future interventions. For further information, see Chapters 7 and 9.

1.10.6 Other drug use

Tobacco use commonly co-exists with other drug use. The National Drug Strategy Household Survey of 2004 examined tobacco use and use of other substances, whether the drug use occurred simultaneously or on separate occasions (Table 1.11). Smokers were more likely to have used any other drug in the past year, compared with non-smokers, and male smokers had a higher prevalence of usage compared with female smokers. Overall, smokers were more than four times as likely to have used marijuana than non-smokers, and were more than three times as likely to have used illicit drugs.43 In 2005, between four and five out of 10 secondary school students who reported having used marijuana, amphetamine, hallucinogens or ecstasy said that they had used tobacco concurrently.104

Most individuals presenting with substance use disorders smoke tobacco as well.103 International92 and Australian95, 105 research shows that in this population, smoking rates range from 68%92 to 90%.95 The relationship between tobacco and other drug use is complex, and may be subject to genetic and neurobiological determinants, as well as psychological and social influences.106, 107 Cessation interventions tailored to the needs of polydrug users are discussed in Chapter 7, Section 7.19.7.