9.2 Socio-economic disparities in tobacco exposure and use: are the gaps widening?

Last updated: December 2016 

Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.2 Socio-economic disparities in tobacco exposure and use: are the gaps widening? 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/9-2-socioeconomic-disparities-in-tobacco-exposure-

While it is clear that smoking rates are higher among disadvantaged than among advantaged groups in Australia, researchers have also sought to examine whether disparities have been widening. The extent of disparities appears to vary over time, as well as depend on the indicator of disadvantage (e.g., education level, vs. socioeconomic status, vs. type of employment) and the sex of the smoker.

Population-wide tobacco-control strategies that reduce smoking at a similar rate of decline in low and high education groups may still (mathematically) result in increasing disparities. Some experts argue that disparity research should focus on maximising reductions in the most disadvantaged group, rather than reducing disparities per se.1

The following sections present data on trends since 1980 in disparities in smoking among adults and children. In sum, the prevalence of smoking has generally declined over time among all disadvantaged groups, regardless of the indicator. Looking at Socio-Economic Indexes for Areas (SEIFA, which comprises relative socioeconomic advantage/disadvantage, based on factors including education, occupation, and economic resources) the absolute gap in smoking prevalence between the most and least disadvantaged has stayed fairly constant since 2004 at about 14%. Some individual-level measures, however, indicate widening. See below for prevalence over time by education level, occupation level, and SEIFA, as well as information on trends in disparities over time in cessation, consumption, and exposure to secondhand smoke.

9.2.1 Changes in the prevalence of smoking among adults in various socio-economic groups

Trends over time in smoking prevalence among different social groups can be difficult to interpret because of changing social and economic conditions. With increasing school retention in Australia and introduction of financial assistance for tertiary students in the mid-1970s, a much more diverse group of people today are achieving higher levels of formal educational qualification compared with that group of people who undertook tertiary education in the late 1960s and early 1970s.

In a period of low unemployment and a buoyant job market, the unemployed in the mid-2000s on the other hand may be less socially diverse than groups who were unemployed during times of low job vacancies in the 1980s and 1990s.

Towards the end of the last decade, the unemployment rate had steadily declined to 4.2% (in 2008); however, as a result of the global financial crisis in the latter part of 2008, unemployment in Australia rose to 5.6% in 2009.2 In 2016, the unemployment rate is about the same at 5.7%.3

Rates of school retention have increased substantially over time.4 Thus, any flattening of smoking rates in people who have not completed Year 12 could be partly attributable to this becoming a group increasingly characterised by social and economic disadvantage. In 2009, the proportion of Australians aged 25–64 years with a vocational or higher education qualification was 63% (compared to 46% in 1997). The increase is mostly attributable to more Australians achieving a higher education qualification, such as a bachelor degree or more. The achievement of higher education relates to the increase in participation in schooling over time. The proportion of young people continuing education through to Year 12 has increased from 45% in 1984 to 76% in 2009.5

Inconsistencies in methods of collecting data and in SES categories over time make long-term analysis difficult. To get a reliable picture of trends in SES-related disparities in smoking, it is therefore useful to look at relative changes across several socio-economic indicators and using several different data sets.

9.2.1.1 Changes in prevalence among those with varying levels of formal education

Figure 9.2.1 sets out the prevalence of current smoking among people with various levels of education between 1980 and 2013 using data collected in surveys conducted by the Anti-Cancer Council of Victoria (ACCV; now Cancer Council Victoria) until 1998, and the National Drug Strategy Household Survey (NDSHS) from 1998 to 2013 (for data for males and females between 1998 and 2013, refer to Chapter 1, Table 1.7.3).

Analysis of data from the NDSHS shows that, between 1998 and 2013, there was a significant linear decline in regular smoking within each education group other than those who had completed up to year 9 or less, where only a trend toward a decline was observed (controlling for age and sex).

Figure 9.2.1
Prevalence of regular* smokers† in Australia aged 18+, 1980 to 1998 (ACCV data) and 1998 to 2013‡ (NDSHS data)—by educational achievement

* Anti-Cancer Council of Victoria (ACCV) data includes those describing themselves as ‘current smokers’ with no frequency specified; National Drug Strategy Household Survey (NDSHS) data includes those reporting that they smoke ‘daily’ or ‘at least weekly’. Note that in the 1998 NDSHS, secondary school education attainment was asked in a different format to 2001 onwards.
† Includes persons smoking any combination of cigarettes, pipes or cigars
‡ Anti-Cancer Council data weighted to 2001 census population data, standardised by age and sex; NDSHS survey data weighted to the Australian population appropriate for each survey year and is not standardised
Source: Hill and Gray 1982,6 1984,7 Hill 1988,8 Hill, White and Gray 1991,9 Hill and White 1995,10 Hill, White and Scollo 1998,11 and Centre for Behavioural Research in Cancer, analysis of data from the National Drug Strategy Household Survey since 1998

As is evident from Figure 9.2.1, the decline in prevalence of smoking for the total 33-year period covered by these surveys was most substantial among those who had a university-level education, but was also substantial among all other groups.

9.2.1.2 Changes in prevalence in blue versus white collar groups

It is widely believed that the gap in smoking prevalence between blue and white collar groups has widened considerably over time.6 However as discussed in Chapter One, Section 1.7, surveys have varied greatly in the age ranges reported and the ways that occupational status has been defined.

Figure 9.2.2 sets out smoking prevalence between 1980 and 2013 for all occupational groups using ACCV data (1980–1998) and NDSHS data (1998–2013) for adults aged 18 years and over.

Figure 9.2.2
Prevalence of regular* smokers† in Australia aged 18+, 1980 to 1998 (ACCV data) and 1998 to 2013‡ (NDSHS data)—by occupation level

Source and notes: See Figure 9.2.1

The decline in prevalence of smoking has been substantial across groups. The declines were proportionately greater among white collar workers than blue collar workers; overall, prevalence of smoking among upper white collar workers declined by just over 70%, while among lower blue collar workers, prevalence dropped by just under 50%.

Smoking rates over the 1980s and early 1990s declined roughly equally in absolute terms among these occupational groups. Disparities appear to have widened briefly in the mid-1990s before the downward trend in smoking resumed in all four occupational groups. Between 1998 and 2013, regular smoking declined linearly among all occupation levels (controlling for age and sex).

9.2.1.3 Changes in smoking prevalence by area-level measures of SES

Figure 9.2.3 shows the prevalence of regular smoking by SEIFA quintiles from 2001 to 2013. Between 2001 and 2013, regular smoking declined linearly among all quintiles (controlling for age and sex). Overall, the absolute gap in smoking prevalence between the most and least disadvantaged has stayed fairly constant since 2004 at about 14%.

Figure 9.2.3
Prevalence of regular* smokers† in Australia, persons 18 years and over, 2001 to 2013‡, by socio-economic index for area

* Includes those reporting that they smoke ‘daily’ or ‘at least weekly’.
† Includes persons smoking any combination of cigarettes, pipes or cigars.
‡ All data weighted to the Australian population appropriate for each survey year and may vary slightly from data presented in previous edition.
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data from 2001 to 2013.

The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage.

Among men, there was a significant linear decline in smoking prevalence among all quintiles except for the most disadvantaged (controlling for age; see Figure 9.2.4).

Figure 9.2.4
Prevalence of regular* smokers† in Australia, males 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: See Figure 9.2.3

Among women, there was also a significant linear decline in prevalence among all quintiles except the most disadvantaged, where only a trend was observed (controlling for age; see Figure 9.2.5).

Figure 9.2.5
Prevalence of regular* smokers† in Australia, females 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: See Figure 9.2.3

9.2.2 Differential uptake or differential cessation?

In the general population, smoking prevalence has reduced due to a combination of fewer people taking up smoking, more people quitting, and more smokers than non-smokers dying prematurely. Figure 9.2.6 shows the proportion of persons who identified as never smokers, across SEIFA quintiles between 2001 and 2013.

Figure 9.2.6
Percentage never smokers in Australia, persons 18 years and over, 2001 to 2013‡, by socio-economic index for area

‡ All data weighted to the Australian population appropriate for each survey year and may vary slightly from data presented in previous edition.
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data from 2001 to 2013.

The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage.

The proportion of never smokers in the most disadvantaged group was 45% in 2001 and 54% in 2013. In comparison, almost 53% of those in the least disadvantaged group were never smokers in 2001 and this increased to about 63% by 2013. Within each quintile, there has been a significant linear increase in the proportion of never smokers over time (controlling for age and sex).

The proportion of men identifying as never smokers significantly increased between 2001 and 2013, across all quintiles (controlling for age; see Figure 9.2.7). In the most recent period of 2010 to 2013, the absolute gap between the highest and lowest SEIFA groups has substantially narrowed; encouragingly, the largest increase in never smokers was in the most disadvantaged group.

Figure 9.2.7
Percentage never smokers in Australia, males 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: see Figure 9.2.6

Figure 9.2.8 shows the proportion of women who identified as never smokers, across SEIFA quintiles between 2001 and 2013. Proportions of never smoking women have significantly increased since 2001 across all quintiles (controlling for age). The gap between quintiles has generally been smaller than in men, although in contrast to men, has widened in recent years; the largest increase in never smokers between 2010 and 2013 was among the least disadvantaged women.

Figure 9.2.8
Percentage never smokers in Australia, females 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: see Figure 9.2.6

Figure 9.2.9 shows quit proportions (i.e., the proportion of ever smokers who have quit) among adults across SEIFA quintiles. While the proportion of adults quitting smoking since 2001 has significantly increased among the second through fifth quintiles, there has been a significant linear decrease in quit proportions among the most disadvantaged smokers (controlling for age and sex).

Figure 9.2.9
Percentage of ever smokers who have quit in Australia, persons 18 years and over, 2001 to 2013, by socio-economic index for area

Source and notes: see Figure 9.2.6

Figure 9.2.10 shows quit proportions among men by SEIFA quintiles. There has been a significant increase in the proportion of men who have quit only among the least disadvantaged group, with a trend also observed in the fourth quintile. The second and third quintiles remained steady over time, while there has been a significant decrease in the proportion of the most disadvantaged men quitting (controlling for age). The data indicate a growing differential between the most disadvantaged and least disadvantaged socio-economic groups.

Figure 9.2.10
Percentage of ever smokers who have quit in Australia, males 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: see Figure 9.2.6

Figure 9.2.11 shows quitting proportions among women by SEIFA quintile. There has been no significant change over time in quit proportions among the most disadvantaged women, while there has been a significant increase among each of the other quintiles (controlling for age). As with males, the higher proportion of quitters in the less disadvantaged groups has led to a widening of the gap.

Figure 9.2.11
Percentage of ever smokers who have quit in Australia, females 18 years and over, 2001 to 2013‡, by socio-economic index for area

Source and notes: see Figure 9.2.6

Earlier research in Victoria, on the other hand, found significant increases in the proportions of regular smokers who had ever made a quit attempt in the low and mid socio-economic groups, but not in the least disadvantaged group. Between the years 2004 and 2010, a significant increase in the proportion of successful quit attempts (in the five years preceding the 2010 survey) was reported for Victorians in the most disadvantaged socio-economic group.7

9.2.3 Changes in consumption of cigarettes

Figure 9.2.12 illustrates consumption levels among smokers of varying occupational levels between 1980 and 2013 using ACCV data (1980–1998) and NDSHS data (2001–2013). Analysis of NDSHS data from 2001 onward shows that average consumption significantly declined in all occupation groups aside from lower blue collar workers, where only a trend was observed (controlling for age and sex). However, consumption was significantly lower among lower blue collar workers in 2013 compared with 2010 (controlling for age and sex), while there was only a trend among upper white collar workers, leading to a narrowing of the gap in recent years (there was no significant difference among the other two groups).

Figure 9.2.12
Self-reported cigarettes smoked (number per day) by Australian adult smokers*†, 1980 to 1998 (ACCV data) and 2001 to 2013‡ (NDSHS data), by occupational level

* Anti-Cancer Council of Victoria (ACCV) data includes those describing themselves as ‘current smokers’ of factory made cigarettes with no frequency specified; National Drug Strategy Household Survey (NDSHS) data includes those reporting that they smoke factory made and/or roll your own ‘daily’ or ‘at least weekly’.
†Includes persons smoking any combination of cigarettes, pipes or cigars
‡ Anti-Cancer Council data weighted to 2001 census population data, standardised by age and sex; NDSHS survey data weighted to the Australian population appropriate for each survey year and is not standardised
Source: Hill and Gray 1982,[6 1984,7 Hill 1988,8 Hill, White and Gray 1991,9 Hill and White 1995,10 Hill, White and Scollo 1998,11 and Centre for Behavioural Research in Cancer, analysis of data from the National Drug Strategy Household Survey since 2001

Figure 9.2.13 shows average consumption over time by SEIFA quintile. Since 2001, there has been a significant linear decline in consumption among the less disadvantaged (fourth and fifth quintiles), and the second quintile, while a trend toward a decline in consumption was observed for the third quintile (controlling for age and sex). No significant change in consumption was observed among those most disadvantaged.

However, as with education level, consumption was significantly lower in 2013 than in 2010 among the most disadvantaged group (controlling for age and sex), and showed the greatest level of decline compared with less disadvantaged smokers. In fact, consumption was significantly lower in 2013 compared to 2010 for all groups other than the least disadvantaged.

Figure 9.2.13
Self-reported cigarettes smoked (number per day) by Australian adult smokers, 2001 to 2013‡, by SEIFA quintiles

Source and notes: see Figure 9.2.6

9.2.4 Changes in the prevalence of smoking among students in schools in areas of varying levels of disadvantage

Higher levels of uptake among disadvantaged groups have traditionally been even more significant than lower levels of cessation as a driver of socio-economic disparities in smoking in Australia. Data on smoking rates among secondary school students of different socio-economic backgrounds can provide an indication of what future smoking disparities may look like.

Figures 9.2.14 and 9.2.15 show weekly smoking rates among young people aged 16 and 17 years and 12–15 years between 1987 and 2014 according to the level of disadvantage of the neighbourhood in which they lived.

Figure 9.2.14
Reported current smoking (smoking in the last week), secondary students in Australia aged 16 and 17 years, 1987–2014, ranked by quartiles of advantage by the area in which the student lived

Sources: T Williams and V White, personal communication, using data from Hill, Willcox, Gardner and Houston;8 Hill, White, Pain and Gardner 1990;9 Hill, White, Williams and Gardner 1993;10 Hill, White and Segan 1995;11 Hill, White and Letcher 1999;12 Hill, White and Effendi 2002;13 White and Hayman 200414 and 2006;15 White and Smith 2009;16 White and Bariola 2012;17 and White and Williams 2015.18

Declines in student smoking rates have been substantial across all quartiles since the late nineties and early 2000s. For the first half of the 2000s, smoking rates appear to follow a social gradient, with the lowest proportion of smokers in the least disadvantaged group. Since then, there is no clear pattern of smoking by socioeconomic status among students aged 16 and 17 years.

Figure 9.2.15
Reported current smoking (smoking in the last week), secondary students in Australia aged 12–15 years, 1987–2014, ranked by quartiles of advantage by the area in which the student lived

Sources: T Williams and V White, personal communication, using data from Hill, Willcox, Gardner and Houston;8 Hill, White, Pain and Gardner 1990;9 Hill, White, Williams and Gardner 1993;10 Hill, White and Segan 1995;11 Hill, White and Letcher 1999;12 Hill, White and Effendi 2002;13 White and Hayman 200414 and 2006;15 White and Smith 2009;16 White and Bariola 2012;17 and White and Williams 2015.18

Among students aged 12–15 years, following a sharp increase in prevalence among the lowest SES students between 1990 and 1996, smoking appears to decline roughly equally among students at all levels of disadvantage until 2005. Recent years have seen smoking rates converge among this age group, with 3% of students in each of the quartiles reporting weekly smoking in 2014.

9.2.5 Changes in disparities in smoking in pregnant women

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9.2.6 Changes in childhood exposure to smoking in the household

The disparity in children living with a smoker has widened over time; in 2001, about the same proportion of the most disadvantaged households with a dependent child contained a smoker (51%) as 2013 (46%), while among the least disadvantaged households, there were far more households with a smoker in 2001 (32%) than reported in the most recent survey (18%).

In contrast, the percentage of households with dependent children that also allow smoking indoors has decreased substantially since 2001 in all SEIFAs, but more so among disadvantaged groups, leading to a narrowing of the gap. The difference in smokefree households between the most and least disadvantaged groups was only about 7% in 2013, compared with 16% in 2001 (and 23% in 2004).

In 2013, more than four in five (82%) of the most disadvantaged households with dependent children and at least one smoker reported keeping their home smokefree (that is, the smoker (or smokers) smoked only outdoors). The proportion of outdoor-only smoking in this group rose by about 31% from 2001. In 2013, in 88% of the least disadvantaged households with a smoker containing dependent children, the person/people who smoked only did so outdoors (see Table 9.2.13).

Table 9.2.1
Percentage of households with a smoker that reported only allowing smoking outdoors in the last 12 months, Australia, 2001 to2013‡, socio-economic index for areas: households with dependent children

Source and notes: see Figure 9.2.6

9.2.7 International comparisons

Observations of smoking and its connection with socio-economic disadvantage are not confined to the Australian population. Survey data in the UK show more rapid declines in smoking among non-manual workers compared with manual workers since the 1970s, contributing to a widening of smoking prevalence between these groups. Smoking was nearly twice as common in routine and manual households as in managerial and professional households (28% compared to 15%). Smoking prevalence was particularly high among economically inactive people aged 16–59 years, whose last job was a routine or manual one; 50% of these people were smokers.19

Observations on growing socioeconomic differences in smoking have also been made in research from Finland,20 New Zealand,21 Italy,22, 23 the US and Canada24-26 and France.27

Similar to the picture in Australia, research in England between 1996 and 2006 found that children from more deprived households were most exposed to secondhand smoke, however across the 11-year research period exposure declined substantially. The most marked declines were observed immediately before the introduction of smokefree legislation in England and among children who were most exposed at the outset.28 Similarly, several studies in the US have found that, despite some ongoing socioeconomic disparities, children’s exposure to secondhand smoke at home has markedly decreased over time.29, 30

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