Last updated: December 2016
Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.1 Socio-economic position and disparities in tobacco exposure and use. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-1-socioeconomic-position-and-disparities-in-toba
Socio-economic disparities are evident in tobacco exposure and use beginning before birth and continuing through childhood, adolescence, young adulthood, and right through adult life. There is a consistent inverse dose-response relationship between cigarette smoking and income level (i.e., the lower the income the greater the smoking), worldwide and across subgroups.1
Disadvantage across a woman’s life course increases her risk of being a smoker during pregnancy.2 Women without a partner, the less educated,3, 4 those of lower socio-economic status,3, 5 those living in a deprived neighbourhood6 and women with a psychiatric disorder7 are more likely to smoke during pregnancy. In 2012, almost half of Aboriginal and Torres Strait Islander mothers reported smoking during pregnancy, compared with about one in ten non-Indigenous women. Younger women are more likely to smoke during pregnancy than older women: more than one-third of teenage mothers smoked during pregnancy in 2012.8 Disadvantaged women may also be more likely to take up smoking during pregnancy or in the early postpartum period,9 and are less likely to quit and more likely to start smoking in their second pregnancy.10
In 2014, among secondary school students aged 12–15, there were no differences in smoking prevalence across different levels of socioeconomic status. Among 16–17 year olds, the most disadvantaged students (those in the 5th quintile) were significantly more likely to be weekly smokers than mid-SES (those in the 3rd quintile), but no more likely to be smokers than the other groups (the second most disadvantaged or the more advantaged students). Figure 9.1.1 shows these proportions by age group.
Proportion reporting smoking at least weekly, secondary-school students aged 12–15 years by relative socio-economic disadvantage of place of residence, Australia, 2014
Source: T Williams and V White, personal communication, using data from White V and Williams T, Australian secondary school students’ use of tobacco in 2014. Centre for Behavioural Research in Cancer, Cancer Council Victoria; 201511
Consistent with findings from the US,12-14 UK,15, 16 Canada,17, 18 New Zealand,19, 20 and other developed countries,21-29 data on current smoking from recent Australian Bureau of Statistics National Health Surveys,30-34 recent National Drug Strategy Household Surveys,35-38 and surveys assessing the impact of the National Tobacco Campaign39 and state Quit campaigns,40 all show a clear social gradient in smoking behaviour among adults, with rates of smoking significantly higher and the proportion of people who have never smoked significantly lower in lower socio-economic groups.
Figures 9.1.2 and 9.1.3 set out Australian data from the 2014–15 National Health Survey published by the Australian Bureau of Statistics.
Prevalence of daily smoking, Australians 15 years and over by socio-economic and labour force status, 2014‒15
Source: Australian Bureau of Statistics 201634
Figure 9.1.3 shows smoking status by level of social disadvantage. The proportion of ex-smokers is almost identical among people living in the least and most disadvantaged areas; differences in smoking prevalence appear to be largely attributable to fewer socially advantaged people taking up smoking in the first place.
Smoking status by quintile of relative social disadvantage, persons 18 years and older, Australia, 2014–15
Source: Australian Bureau of Statistics 201634
The 2013 National Drug Strategy Household Survey tells a similar story. The disparities between the least and most disadvantaged are much greater among never and current smokers than among ex-smokers. Table 9.1.1 shows smoking status among those of varying levels of social disadvantage, employment status, and education level.
Socio-economic characteristics by smoking status, persons 18 years and older, Australia, 2013
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2013.41
* Never smoked more than 100 cigarettes or the equivalent tobacco in their life
† Smoked at least 100 cigarettes or the equivalent tobacco in their life, and no longer smoke
‡ Smoked daily, weekly or less than weekly
In addition to being more likely to have ever smoked and to be current smokers, those in disadvantaged groups also generally report smoking a greater number of cigarettes each day.30, 42, 43 Table 9.1.2 shows the average number of cigarettes smoked per day among adult smokers by social characteristics in Australia in 2013.
Mean number of cigarettes smoked per day, (self-reported) current smokers aged 18 years and older, by social characteristics, by sex, Australia, 2013
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2013.41
Among people who have quit smoking, those with lower levels of occupation, income and education are likely to have smoked for longer periods of time prior to quitting. Table 9.1.3 sets out the mean number of years spent smoking prior to quitting for people who reported being ex-smokers in the 2001 National Drug Strategy Household Survey.44, 45
Mean duration of smoking prior to quitting, Australia, 2001
Source: Siahpush et al 200545
Results of multivariate analysis showed that smoking duration from onset to cessation was 14% longer for persons with blue collar rather than professional occupations. Respondents who earned $299 or less per week smoked 38% longer than did those earning $800 or more. Individuals with nine or fewer years of education smoked 13% longer than those with 12 or more.
Note, however that trends in smoking cessation are not uniformly more favourable in higher SES groups for all age and gender groups. In 2013, older women (60+ years) with the highest educational attainment (at least some university) were significantly more likely to have ever smoked than those with the lowest level of attainment (year 11 or less). The opposite was true for middle aged (40–59 years) and younger (18–39 years) women; those with a university education were significantly less likely to have ever smoked than those with lower education levels.41 International research has shown similar patterns.46 These differences in patterns of uptake between cohorts may be explained by trends towards greater social freedom for women since the late 1960s.
In the US, there also appear to be marked differences in the duration of smoking between racial and socio-economic groups. One study found that most minority racial groups were likely to smoke for longer periods and individuals living in poverty smoked on a daily basis for 18 years longer than those with a family income about three times above the poverty line.47
Cohort patterns in smoking uptake and quitting are discussed further in Section 9.7
People in more disadvantaged groups are also more likely to be exposed to secondhand smoke both where they work and where they live.
Children from disadvantaged families are far more likely to be exposed to secondhand smoke at home. Lower household income, lower parental (or head of house) education level, and living with multiple adult smokers are predictive of children’s exposure to smoking in the home.48, 49
Data from the National Drug Strategy Household Survey show that in 2013, about 30% of households with at least one child under 15 reported having a household member that smokes at least once per day (see Table 9.1.4). Within these households with children, almost two in five (18%) in the most disadvantaged areas reported that the smoker smokes inside the home, compared with 12% within the most advantaged. Put another way, 82% of the most disadvantaged households kept their home smokefree, compared with 88% of the least disadvantaged. Given the higher rates of smoking among those in the disadvantaged groups, this means that children from the most disadvantaged areas of Australia were almost four times more likely to be potentially exposed to smoking in their own homes as children from the most advantaged areas. About 8% of these highly disadvantaged children live in a household where someone smokes indoors at least once a day.
Percentage of households with children under 15 years that allow indoor smoking, by quintile of disadvantage*, Australia, 2013
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2013.41
* Based on socio-economic indexes for areas, Australian Bureau of Statistics
Although some children of low socio-economic status (SES) smokers are exposed to tobacco smoke in the home, legislative developments, such as Australia-wide bans on smoking in cars carrying children (see Chapter 15, Section 18.104.22.168), and bans in some states/territories on smoking in close proximity to schools and playgrounds, help reduce the number of areas where children may be exposed to secondhand smoke. Widespread smokefree legislation means that children of non-smoking parents might only very rarely be exposed to environmental tobacco smoke.
International research shows the same associations between deprivation and the likelihood of secondhand smoke exposure in children, with maternal and paternal smoking habits, household poverty, and lower parental educational levels being common predictors of exposure.48-51
Since the mid-1980s in Australia, when smoking was banned in the federal public service offices and then, increasingly in big and then smaller companies (see Chapter 15, Section 15.4), people in higher status occupations have been more likely to work in places with total bans on smoking. While most workplaces since the late 1980s have restricted smoking to at least some degree, research in the late 1990s found that blue collar workers were three times more likely to work in environments with no restrictions on smoking (see Figure 9.1.4).
Proportion of workers reporting a total ban and proportion reporting no restrictions on smoking in their workplace, Australia 1998: blue collar compared to white collar and professional workers
Source: Adhikari and Summerill 199852
With legislation mandating smokefree policies in hospitality venues and in enclosed workplaces in all Australian jurisdictions (with some exemptions, such as high-roller rooms), disparities in workplace exposure to environmental tobacco smoke are no doubt much less pronounced in more recent times. Data collected from annual population surveys in Victoria showed for instance, that the proportion of indoor workers reporting total smoking restrictions at their usual area of work increased significantly between 1998 and 2007, from 91% to 95%. The data indicated there was a relatively uniform increase in workplace smoking bans across all socio-economic groups for this period. However, there was still some disparity between smokefree workplaces, with 91% of warehouse, workshop, and factory workers reporting a smokefree workplace compared to the average of 95% of all indoor workplaces.53
In the 2013 National Drug Strategy Household Survey, among households with a smoker, about one in five (21%) reported that the smoker smoked daily inside the home. Looking at education level, 19% of people who had completed year 12 or higher reported that the smoker smoked inside, compared with about one quarter (24%) of those who had only completed up to year 11 or less. Similarly, 27% of households with a smoker in the most disadvantaged areas reported daily smoking in the home, compared with 17% of those in the most advantaged areas (see Figure 9.1.5).
Proportion of households with a smoker that allow smoking indoors by SEIFA and education level, Australia, 2013
In 2008–09, 82% of university-educated smokers reported never smoking when non-smokers were present in their cars—only slightly more than smokers who had not completed high-school education (Figure 9.1.6).
Current smokers’ smoking behaviour around non-smokers in cars, by educational status, Australia 2008–09
Source: Data file of responses to seventh wave of the International Tobacco Control Four-country Survey provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, 2012
Note: Figures are percentages
People spending time in institutions such as correctional facilities, psychiatric hospitals, and drug treatment centres are among the most disadvantaged groups in Australia. Given the much-higher-than-average rates of smoking among residents and clients of such facilities and services, high levels of smoking among staff,54, 55 and fears about the impact on attendance, treatment, and behaviour,56 it is only in recent times that such institutions have begun to introduce comprehensive smokefree policies. For example, all states and territories except Western Australia have introduced or are planning to introduce complete smoking bans in prisons, and many inpatient psychiatric settings have implemented smokefree policies. Poor adherence and low levels of support in such settings may, however, limit their effectiveness, resulting in levels of exposure to secondhand smoke among highly disadvantaged clients in such facilities much higher than in the general population.57
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