9.6 Smoking, ill health, financial stress and smoking-related poverty among highly disadvantaged groups

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In addition to the differentials in smoking among broad categories of socioeconomic status, it is also clear that smoking rates are even higher among many groups of highly disadvantaged people. The financial stress resulting from expenditure on tobacco products and the immediate and longer term effects of smoking exacerbate the problems of many people grappling with intensely difficult personal challenges and social alienation due to a variety of life circumstances, events and choices.[19]

9.6.1 People living in regional and remote areas of Australia

About 31.5% of Australians live outside major cities (that is, cities with populations greater than 250,000): 68.5% live in major cities, 29.2% in regional areas and 2.3% in remote or very remote areas.169

People living in rural or remote Australia tend to suffer lower health status. They work in more risky occupations and must travel long-distances over country roads. They also are much more likely to smoke, be obese, to drink alcohol in hazardous quantities and to be physically inactive.170 Financial stress due to prolonged years of drought is affecting many people employed in the agricultural sector living in rural and remote Australia, with increasing awareness of depression among men in particular.

Analysis of 2004–05 ABS National Health Survey data shows that, after adjusting for age differences, 33% of adults in remote Australia reported being current smokers in comparison to 22% in major cities, 26% in inner regional and 28% in outer regional Australia.58 People living in rural and remote Australia also have higher mortality rates than those living in urban areas, including for heart disease and lung cancer[20].170, 171

Living some distance from major population centres country people often lack access to specialist medical and other health services. Because health professionals are in such short supply in rural and remote areas, it is often difficult to find time for preventive health activities. As recognised in the National Tobacco Strategy,8 availability of pharmaceutical treatments and free telephone and internet services providing advice and assistance to quit are therefore very important for Australian smokers living in rural and remote areas. While all Australians have access to the Quitline, call-back programs have not been available in several states. Improving access to such treatment services is acknowledged as a priority in Australia's National Tobacco Strategy.8, 172

9.6.2 People born overseas

According to the most recent Census, about three out of every 10 Australian residents were born overseas, and about two in 10 Australians speak a language other than English at home.173

Moving countries profoundly changes peoples' lives. For many it provides escape from poverty and violence; it almost always gives people the chance, if not to improve their immediate economic situation, to at least provide a much better future for their children. With this may come great optimism and sense of purpose, and strong bonds with and support from others living nearby from the same cultural background. Immigrant populations generally enjoy better reported health and lower rates of disability and hospitalisation than those reported by people born in Australia.174[21]

But immigration can also result in quite extreme social and cultural isolation and many people who move to Australia from non-English speaking countries are further disadvantaged by lack of access to information, limited employment opportunities due to less facility with English, and lack of recognition of educational and professional qualifications gained overseas.[22]

So does the migrant experience translate into greater risk of smoking?

For daughters of parents coming to Australia from Asian, African and Middle Eastern countries where female smoking rates are generally very low, contact with other Australian girls may result in a greater risk of smoking uptake.[23] Further, among migrants who are already smokers, the stresses associated with establishing a new life in Australia may work against success in quitting.

However, equally it is also possible that moving to Australia increases the likelihood of quitting in those groups who come from countries with less developed tobacco control policies.[24]

Overall it would seem that being an immigrant or speaking a language other than English is not a risk factor for smoking.

People from non-English speaking backgrounds are less likely to smoke than those where the major language spoken at home is English.19, 31 Data from the National Health Survey suggest that more than 22% of people who speak English at home smoke at least weekly compared to only 17% who do not speak English at home31, 58 with similar results evident in the National Drug Strategy Household Survey (where prevalence of smoking among people 14 years and over who spoke a language other than English at home was about 14%).19 People migrating to Australia after 1996 are slightly less likely to be smokers than those arriving prior to 1996, and are also less likely to smoke than the Australian population as a whole (see Chapter 1, Table 1.8).

However, it also has to be recognised that people in some cultural and linguistic communities smoke at very high rates indeed. In the Arab-speaking population in Sydney, more than 50% of both males and females smoke;177 among the Sydney-based Lebanese community, about 49% of males and 29% of females are smokers;178 and male members of the Vietnamese community in Sydney have smoking rates of 53%.179 Studies from New South Wales show that while schoolchildren within these families from high-smoking communities have a lower prevalence of smoking than their counterparts from English-speaking homes180, older teenagers are more likely to take up smoking once parental controls reduce.178, 181

While being born overseas in itself is not a risk factor for smoking, being a member of a community where smoking is common may increase health and financial problems of families affected.

High levels of smoking in both men and women of Arabic, Lebanese, Turkish and Eastern European backgrounds, and among men of Chinese, Vietnamese and other Asian backgrounds must be resulting in high levels of exposure to second-hand smoke for all family members.

As with other disadvantaged smokers, smoking must also contribute to financial stress. With prices of tobacco products much higher in Australia than in their countries of birth, spending on tobacco products among recent immigrants who smoke must significantly reduce funds available for family goals such as saving for a home, education in a private school and assisting other family members both in Australia and overseas.

In line with higher-than-average smoking rates, death rates (male and female combined) from lung cancer among those born in Croatia, the Netherlands and the UK and Ireland are significantly higher than rates for the Australian population as a whole.182

People from cultural backgrounds where smoking is prevalent may face cultural resistance to quitting due to traditional beliefs and attitudes to smoking.177 Continued smoking by family and friends may make it harder to contemplate quitting and increase chances of relapse in those who give it a go. People from culturally and linguistically diverse (CALD) backgrounds also lack access to information due to language barriers.

Providing education and support to Australians with different cultural backgrounds provides particular challenges for public health policy, as has been recognised by the National Tobacco Campaign183 and the National Tobacco Strategy.8

9.6.3 Lone parents, especially lone mothers

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 were cared for in a family with one parent.67 Eighty-seven percent of lone parents bringing up children aged under 15 are women.67 Lone mothers are among the fastest growing demographic groups. In the period between 1974 and 1998 the percentage of families with dependent children who were headed by a lone mother more than doubled, from 7.7% to 16.7%.

Lone mothers and their children are one of the most disadvantaged groups in many countries184 and suffer higher risks of poverty and ill health than other family types.185, 186

In 2003–04, 49% of one-parent family households with children under 15 years were simultaneously in the lowest three deciles of income and of net worth. This compared with 11% of couple families with children under 15 years.67

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%).187 Lone mothers who were younger, less educated, received government pension/benefits, occupied rental housing, or who lived in more disadvantaged areas were more likely to smoke than others. A strong 'lone mother effect' remained after controlling for socioeconomic variables. The odds of smoking for lone mothers were 2.4 times greater than for married mothers (95% CI: 2.0-2.9) and twice as large as those for women living alone (95% CI: 1.6-2.4).188

As highlighted by Hilary Graham in her extensive research and writing about smoking in lone mothers in the United Kingdom,1, 15, 185, 189–193 smoking status among this group is associated not just with the difficult circumstance they face in the present,194 but also by 'longer term biographies of disadvantage.'195

Lone mothers are much less likely than mothers with partners to quit or suspend smoking during pregnancy. And mothers who continue to smoke during pregnancy are much more likely to report having a difficult, fussy baby, further adding to the stress of looking after children without a partner present.156, 196

Children of lone parents are much more likely than children of two-parent families to be exposed to tobacco smoke indoors.

About a third of lone-parents with dependent children whose households are located in the most disadvantaged areas of Australia report that they smoke indoors at home at least once each day.45 Children who live in households headed by a single parent are two-to-four times more likely to be exposed to second-hand smoke at home indoors than children from two-parent families living in similar areas. They suffer from more respiratory diseases197 and respiratory illnesses occur more frequently and more severely in those exposed to environmental tobacco smoke.198 Children of lone parents who smoke are also much more likely than children in two parent families (and than children of lone parents who do not smoke) to begin smoking as teenagers,199, 200 thus the effects of smoking are perpetuated across the generations.

9.6.4 People living with mental illnesses

Mental health problems are common within the Australian population, with one in 10 Australians (children and adults) reporting a long-term mental or behavioural problem such as anxiety, depression or substance abuse31 and 3% of adults suffering from a serious mental illness such as manic depression or schizophrenia.201 In the National Mental Health and Well-being Study conducted by the ABS in 1997, just over 17% of adults reported a mental health problem in the previous year.202 In the National Drug Strategy Household Survey, about one in 10 people reported suffering psychological distress within the previous four weeks.19

9.6.4.1 Mental illness and disadvantage

People living with serious mental illnesses are very seriously disadvantaged in employment, housing, and just about every sphere of life.

Current tobacco use is strongly associated with a range of other substance use and mental health problems.203 Mental health problems are higher in the other highly disadvantaged groups discussed in this section.

9.6.4.2 Smoking among those with long-term mental or behavioural problems

Individuals with mental health conditions have a higher prevalence of smoking and those who smoke, tend to smoke more heavily than the general population.204, 205

Population surveys have reported smoking rates of at least 30% among people suffering from common mental health problems such as anxiety and depression, compared to about 21% of the total population19, 31, 206 and about 20% of people not suffering such problems.19

Conversely, mental health problems are also much more likely among those who are smokers.203

International research indicates that smoking rates are higher among gamblers than non-gamblers (32% compared to 21% in a study in Ontario, Canada, in 1994).207 Rates are particularly high among problem gamblers, with international studies of prevalence ranging from 43% to 83%.208

9.6.4.3 Smoking among those with serious psychiatric illnesses

Australian research has reported rates of up to 73% in men and 56% in women suffering from serious psychiatric illnesses (including major depression, anxiety and panic disorders, post-traumatic stress disorder, neuropsychiatric disorders and psychotic disorders such as bipolar disorder).201, 204, 205 A review of 42 international studies in 20 nations found an average smoking prevalence among people with schizophrenia of 62%.209

Highest rates of all are observed among those with a diagnosis of psychosis.205 Psychotic illnesses are characterised by fundamental distortions of thinking, perception or emotional response and include bipolar affective disorders and delusional disorders. People with mental health illnesses who live in institutions have higher rates of smoking than those living in the community.205

The interaction between tobacco use and mental illness is complex and likely to reflect a number of factors.

For in-patients in an institution, environment may reinforce smoking behaviour.210 Many patients report smoking more due to boredom.211 Smoking may also be seen as a means of reclaiming a degree of self-determination and autonomy in the face of disempowerment.212 Although most patients with a psychiatric condition report that they smoke for the same reasons as other smokers (including 'addiction', for 'relaxation' and to 'calm down',213–215 there is evidence that nicotine may serve for some as a form of self-medication to ameliorate symptoms of certain mental illnesses, or to alleviate side effects of prescribed medication.205, 213, 214

9.6.4.4 Financial stress among those with mental illness who smoke

In Australia in 2000, it has been estimated that people with a psychotic illness who smoked and were in receipt of a disability support pension spent more than one-third of their pension on tobacco products, and contributed a total of about $111 million each year in tobacco taxes to the Australian government. According to this study, smoking contributes to the vicious cycle of poverty and disadvantage in which many people who are living with mental illness are trapped.212

Smoking prevalence is also very high among people that call helplines for problem gamblers (over 43% in one US study).216

9.6.4.5 Preventable diseases among those with mental illness who smoke

The higher rates of smoking among people with mental health problems and mental illnesses means that they are more likely to suffer all the various health problems associated with tobacco use. People with mental illness may not be as frequently or intensively counselled about preventive health issues by health practitioners very much focused on managing immediate symptoms of mental illness.217

American research has indicated a 20% reduction in life expectancy among people suffering from schizophrenia218 with heart disease being the most common cause of death.219

9.6.4.6 Barriers to cessation among those with mental illness

People with mental illnesses who smoke may face added difficulties with quitting, and symptoms associated with their mental illness may be exacerbated among those who do attempt to quit.220, 221

Smokers who suffer from severe mental health illnesses, and those living in institutions, have been identified in the Australian National Tobacco Strategy8 as requiring specialised strategies to assist in cessation. For further discussion on cessation in this target group, see Chapter 7, and Section 9.10.3.

9.6.5 People with alcohol and drug problems[25]

People with mental health problems are also much more likely to suffer from alcohol and other drug problems including smoking222 and tobacco use commonly co-exists with other drug use—see Chapter 1, Section 1.10.6.

Most individuals presenting for treatment for substance use disorders smoke tobacco as well.223 Australian research203, 215, 222 shows that in this population, smoking rates range from 68% to 90%.215 Among mentally ill in-patients with co-existing alcohol and other drug problems, smoking rates as high as 90% have been observed.215

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.224, 225

As pointed out by Baker et al, those with substance abuse problems who also smoke tobacco

'… are at particularly high risk of experiencing harm as a consequence of a typically heavier pattern of tobacco use … and due to the synergistic effects of these substances. It has been estimated that the combined health risks of smoking and alcohol use are 50% higher than the sum of their individual risks. For example in the case of oesophageal cancer, the excellent solvent properties of alcohol may take the carcinogen in tobacco smoke to basal layers. In addition, people with severe alcohol and drug dependence problems are more likely to die from tobacco-related causes such as coronary heart disease, cancer, stroke and chronic lung disease, than from caused related to the use of any other drugs.' Baker et al, 223 p 87

The National Tobacco Strategy8 has recognised the need for tailoring of treatment to those people with alcohol and other drug problems. Cessation interventions tailored to the needs of poly-drug users are discussed in Chapter 7, Section 7.19.7.

9.6.6 The homeless

Homelessness is defined as lacking adequate access to safe and secure housing. The Australian National Census showed that there were about 100,000 homeless people in Australia in 2001.226

Homeless populations are growing due to pressures in the housing market resulting in large recent increases in house prices, high interest rates and low rental occupancy rates.227–229

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.230 Melbourne-based research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%.230

People who live 'rough' are unlikely to see media advertising about the dangers of smoking. Unrestricted smoking outdoors is likely to result in the development of high levels of dependence on tobacco-delivered nicotine.

9.6.7 Prison populations

In 2007 just over 27,000 people were detained in prisons in Australia.231 At any one time in a year, as many as a further 1000 people are being held in immigration detention centres.232

The prevalence of smoking in the prison population is far higher than among the general population,233, 234 and tobacco use is commonly accepted as part of prison life.234 It is not unusual for tobacco to be used as currency in gambling or other trade.234

Research undertaken in 2001 examining smoking among New South Wales prisoners found that 78% of male and 83% of female inmates were smokers.234 Most (95%) inmates smoked roll-your-own cigarettes, a far higher proportion than that seen in the rest of the population.234 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.234 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%).234

The elevated smoking rates in the prison population reflect, to a large extent, increased likelihood of disadvantaged socioeconomic backgrounds in inmates.235 Indigenous people make up over a third of the prison population.231 Drug users, and the less educated are over-represented in the prison system, as are those suffering mental disorder (77% compared with 22% in the overall population).236 Prisoners are 20 times more likely to suffer psychosis, four times more likely to suffer an affective or anxiety disorder and seven times more likely to suffer a substance use disorder.182 All of these mental health problems are associated with high rates of smoking.223, 234

Exposure to second-hand smoke in prisons must be very high, even since smoking has been increasingly restricted in indoor areas.237 Ill health due to tobacco and spending on tobacco products must create significant challenges for prisoners trying to secure a job and a safe and secure place to live once they are released from prison. Both these factors reduce the chances of reoffending and are crucial for the successful transition to life outside prison.

The Australian National Tobacco Strategy8 has identified the prison population as a priority area for future interventions.

9.6.8 Veterans

A total of 261,200 Australians alive in June 2005 were enlisted or engaged in World War 11, the Korean or Vietnam wars or other pre- and post-1972 conflicts.182

It is estimated that about one in every two of the veteran population has some mental health concerns, with 56,000 classified by the Department of Veterans Affairs as having a mental health disability.238

While military personnel have one of the highest rates of smoking among adults in the United States,239 little information is available about current smoking rates among either active service personnel or veterans in Australia. Based on the relative incidence of smoking-related cancers, smoking rates among veterans of the Korean War are believed to be higher than those of the general population.240 Smoking may interact with exposure to other carcinogenic agents during war service, resulting in higher cancer rates in this group.

9.6.9 Indigenous communities

Aboriginal and Torres Strait Islander people make up 2.3% of the Australian population.173 Indigenous Australians have the worst health of any population group in Australia. In Queensland, Western Australia, South Australia and the Northern Territory combined, their life expectancy is 24 to 27 years less than that of non-Indigenous Australians.241 They experience two to eight times the death rate of non-Indigenous people across all age groups.242

9.6.9.1 Disparities in tobacco use between Indigenous and non-Indigenous Australians

Current smoking prevalence

Data from the ABS's 2004–05 National Aboriginal and Torres Strait Islander Health Survey indicate that approximately 50% of Indigenous people reported smoking at least one or more cigarettes per day. For both men and women, smoking was more prevalent among Indigenous than non-Indigenous adults in every age group.243

After adjusting for age differences between the two populations, Indigenous adults were still more than twice as likely as non-Indigenous adults to be current daily smokers.

As with the total population, among Aboriginal and Torres Strait Islander peoples, smoking levels are higher among more disadvantaged groups. In a snapshot of smoking among Indigenous communities244 the ABS reports

• 'In 2004–05, Indigenous adults who had completed Year 12 were less likely to be regular smokers than were those who had completed Year 11 or below (34% compared with 55%).
• Daily smoking was less common among employed Indigenous adults (45%) than among those who were unemployed (66%) or not in the labour force (53%).
• Indigenous adults with access to higher household incomes were less likely than those in low income households to be regular smokers (40% compared with 55%).'244

Disparities in duration of smoking

In its snapshot of tobacco smoking in Indigenous communities,244 the ABS reports

• 'In 2004-05, one in 10 Indigenous adults who were current daily smokers or ex-smokers had begun smoking regularly before the age of 13 years, compared to one in 20 of non-Indigenous adult smokers and ex-smokers. Indigenous women were more than twice as likely as non-Indigenous women to report having begun smoking regularly before the age of 13 years (9% compared with 4%).
• More than two-thirds of Indigenous current daily smokers and ex-smokers (68%) had begun smoking regularly before the age of 18 years, compared to 54% of non-Indigenous current daily smokers and ex-smokers
• Indigenous people living in non-remote areas tended to commence regular smoking earlier, with 11% starting before the age of 13 years compared with 5% in remote areas.'

Disparities in exposure to second-hand smoke

The ABS also reports that

• 'In 2004-05, 111,800 households with Indigenous residents (62%) had at least one regular smoker. Of these households with a regular smoker, 45% had at least one resident who regularly smoked indoors.
• Two-thirds (66%) of Aboriginal and Torres Strait Islander children aged 0-14 years lived in households with one or more regular smokers and 28% lived in households in which at least one resident regularly smoked indoors.
• About one-third of non-Indigenous children aged 0-14 years (35%) lived in households with a regular smoker and 9% lived in households in which at least one resident regularly smoked indoors.' 244

Disparities in smoking in pregnancy

Data from the AIHW National Perinatal Data Collection indicate that Aboriginal and Torres Strait Islander mothers smoke during pregnancy at about three times the rate of non-Indigenous mothers (52% compared to 16%).241[26]

9.6.9.2
Is the disparity getting worse?

While smoking rates have declined substantially in the overall population over the decade to 2005, the ABS's Aboriginal and Torres Strait Islanders Health surveys record very little change in the rate of smoking by Indigenous people since 1995.243

9.6.9.3
Contribution of smoking to ill-health in Indigenous communities

Self-reported health status

The ABS reports

• 'In 2004–05, Aboriginal and Torres Strait Islander people who had never smoked were more likely to report being in excellent or very good health (47%) than were ex-smokers (41%) or current daily smokers (35%).
• Correspondingly, Indigenous people who were current daily smokers or ex-smokers were more likely than those who had never smoked to report being in fair or poor health (27% compared
  with 17%).

Disability and long-term health conditions

Indigenous Australians are four times more likely to suffer from diabetes mellitus than non-Indigenous populations, and the prevalence of reported asthma is 25% higher.31, 243

The ABS reports244

• 'In 2002, Indigenous people who were current daily smokers were more likely than those who had never smoked to report having a disability or long-term health condition (40% compared with 31%). They were also more likely than those who had never smoked to report a profound or severe core activity restriction (9% compared with 6%).

Also,

• About 24% of current daily smokers and 37% of ex-smokers reported respiratory diseases.

Indigenous Australians are 17 times as likely to require hospital care involving dialysis, and three times as likely to be hospitalised for respiratory diseases. (AIHW National Hospital Morbidity database, summarised in Table 4.13 AIHW Health 2006182)

Tobacco smoking was responsible for 12.1% of the total burden of disease in Indigenous Australians in 2003, and one-fifth of deaths. Tobacco use explains 35% of all cancer deaths, compared with 21% in the general population.

9.6.9.4 Social disadvantage and smoking within Indigenous communities

Among Aboriginal and Torres Strait Islander peoples, higher socioeconomic position is associated with being a non-smoker rather than a smoker. An analysis of data from the 2002 National Aboriginal and Torres Strait Islander Social Survey found that this held for nine measures of socioeconomic position: income, education, employment, receiving or not receiving a government pension, suffering or not suffering financial stress, owning versus not owning your own home, having or not having access to a motor car and having or not having access to computers and the internet.245 Indigenous people who had not been removed from their natural family were twice as likely to be non-smokers, to never have smoked and to have quit. This association was the same even after controlling for age, gender and SES variables.

9.6.9.5 Smoking and intergenerational poverty in Indigenous communities

Nowhere are the dynamics of intergenerational poverty played out more clearly in Australia than in our Indigenous population.

Spending on tobacco products

Spending on tobacco products is a cause of financial stress in many Indigenous communities.246, 247 Indigenous people who report that they had experienced financial stress in the past year were more likely to be daily smokers than were those whose household had not experienced financial stress (58% compared with 41%) according to the ABS in 2007244

Indigenous Australians enjoy much lower rates of home ownership than other Australians. Only 8.3% of Indigenous people live in houses being purchased by one of the occupants. This represents only 4.7% of all Indigenous households, and compares to 70% of households owned or being purchased by one of its occupants in the Australian community as a whole.67

As discussed in Section 9.5.1, spending money on tobacco products makes it hard to save for the future. Living in rental accommodation is highly predictive of current and future housing-related poverty. For many families, buying a house is what ensures a comfortable standard of living in older age, and the creation of an asset that can be passed on to your children. Less tangibly it provides stability and a sense of security.

Even controlling for age and gender, Indigenous people who live in dwellings that are owned or being purchased by the occupants are almost three times less likely to smoke regularly than are those who live in rented dwellings.245

The long-term effects of smoking during pregnancy

Consistent with the elevated levels of smoking in pregnancy (three times the rate of the non-Indigenous population) as well as poorer nutritional status and other risk factors, almost 13% of babies born to Indigenous mothers in 2003 were classified as low-birth weight, compared to 6% for babies of non-Indigenous mothers. Low birth weight is associated with a range of childhood diseases and with the development of Type 2 diabetes, a leading cause of disease and death in Indigenous communities.

Exposure to environmental tobacco smoke and school absences

According to the 2001 ABS Census of Population and Housing, an estimated 10% of Indigenous household were overcrowded, translating to an estimated 22% of Indigenous people living in overcrowded conditions. Overcrowding is also associated with higher levels of mental health problems and higher rates of smoking.248

With more overcrowding and higher smoking rates among adults, Indigenous children are much more likely to suffer respiratory diseases and asthma attacks triggered by smoking. Such illnesses are a major cause of school absences,158 and frequent school absence is a major contributor to poor academic performance and educational failure.249

Special factors associated with smoking and tobacco control in Indigenous communities are discussed at length in Chapter 8.

9.6.10 Vulnerable youth

While generally they enjoy very good health, obesity, depression and asthma are all common in young Australians aged 13 to 20 years.182 All conditions are relevant to the development of tobacco-related disparities, and all are more common among teenagers from disadvantaged backgrounds.250

About one in eight young people in Australia suffer from asthma,31, 251 and asthma attacks are more common and more severe in young people exposed to second-hand smoke.252 Disadvantaged parents are much more likely to smoke indoors than more advantaged parents.44 Asthma symptoms are more poorly managed and more frequent in children who live in families in more disadvantaged neighbourhoods.250

In addition to exposure to second-hand smoke, Indigenous children and children of non-Indigenous lone mothers, people suffering mental disorders, people with substance abuse problems and prisoners must all be at particular risk of harm caused by tobacco use. Spending on tobacco products in low-income families can mean reduced expenditure for recreational activities, education and even food for children in very disadvantaged families.253 Such children are much more likely to lose a parent (and breadwinner) due to illness and premature death caused by smoking. Absence of smoking restrictions at home is associated with increased risk of smoking uptake by children.167, 168 Smoking by parents is highly associated with the uptake of smoking and other high-risk behaviours in children.254

Young people from disadvantaged families who are already themselves facing difficult personal circumstances are at particularly high risk of taking up smoking.

Almost one in eight young people (13%) had a mental health problem according to the National Mental Health Survey conducted in 1997.29 Mental health problems in young people are strongly associated with engagement in risky behaviours.160, 255 Smoking rates are high among young people in institutional care,256 and smoking is often not routinely addressed in drug treatment and child and adolescent mental health services.

In 2004, 10,857 young women under 20 years of age had a baby. Forty-two percent of these teenagers smoked during pregnancy.40 Compared to teenagers who don't smoke, teenagers who smoke are almost 60% more likely to have a baby of low birth weight.257

One international study suggests that smoking by adolescents may limit their subsequent life chances independent of the effects of socioeconomic status.258 Anecdotal evidence suggests that smoking status in Australia may be starting to affect employability and to limit choices in housing and in dating259 and, therefore perhaps also in the establishment of long-term relationships.