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

While it is clear that smoking rates are higher among disadvantaged than among advantaged groups in Australia, much less clear is whether disparities have been widening over time. The answer depends most crucially on the period of time over which one analyses the data. In addition, the extent of differential changes in rates in different socio-economic (SES) groups also seems to vary depending on the indicator of SES status, the data set and the jurisdiction being examined.

An assessment of the impact of the Californian Tobacco Control Program in reducing prevalence in higher-educated and less-educated population groups provides insight into the complexity in measuring the effect of strategies to reduce relative disparity between groups. Zhu and colleagues explain that population-wide tobacco-control strategies that are known to be effective in reducing smoking prevalence may not necessarily work to reduce disparity between population sub-groups. They note the challenge in tobacco control lies in eliciting an increase in the rate of change in less-advantaged groups, so as to reduce disparity between less-advantaged and more-advantaged groups.1

The factors that serve to negate the effects of population-wide strategies among the most disadvantaged are addressed in Sections 9.4 and 9.5 and considerations around the impact of population-wide strategies on the disadvantaged appear in Section 9.8.

Insufficient data are available to examine trends over time in smoking during pregnancy, however the following sections present data on trends since 1980 in disparities in smoking by adults, together with limited data about emerging disparities among children.

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,i a much more diverse group of people in the 1990s 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 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 2009.3

Rates of school retention have increased since 1998 among young people.4 Also, increasingly over time people born prior to World War II (who are much less likely to have completed school)5 are being lost from the total population. Thus, part of the explanation for any flattening of smoking rates in people who have not completed Year 12 could be that this is becoming a group characterised by more social and economic disadvantage than was the case in previous cohorts. In 2009, the proportion of Australians aged 25–64 years with a vocational or higher education qualification was 63% (compared with 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 2009.2

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

Table 9.2.1 sets out the prevalence of current smoking among people with various levels of education between 1980 and 2010.ii Adjusting for age and gender, analysis of these data shows that the prevalence of smoking found in every educational level in 2010 was significantly lower than that found in 1980.

As is evident from Table 9.2.1, the decline in prevalence of smoking for the total 30-year period covered by these surveys was most substantial among those who had graduated from university, but was also substantial among those who had finished secondary school and those who left school before Year 10.

Table 9.2.1
Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment

Education level

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007

2010

Drop

Reduction (%)

Year 9 or less

35.5

35.8

31.9

30.4

29.8

30

27.9

23.9

22.8

24.3

24.1

12.7

36

Year 10 & 11

37.9

37.6

34.9

31.9

29.5

30.5

32.7

29.9

30.0

28.5

26.7

7.9

21

Year12/post-secondary

37.6

34.1

32.9

28.4

29.1

23.5

28.2

22.0

22.0

20.6

19.1

15.6

41

Trade

34.9

34.4

29.6

29.4

29.2

25.6

28.2

27.2

28.3

26.1

25.6

6.6

19

University

28.8

28.6

22.9

21.3

19.6

20

20.1

14.8

13.3

12

11.6

15.5

54

Sources: 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 White et al 2003;12 Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 201116

Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 1980–98, 6–12 and from the National Drug Strategy Household Survey 2001–1013–16. See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as 'current smokers' (no frequency specified). Since 2001, the figures include those reporting that they smoke 'daily' or 'at least weekly'.

All data weighted to 2001 census population data and may vary slightly from data presented in the previous edition

* Includes persons smoking any combination of cigarettes, pipes or cigars

Figure 9.2.1

Figure 9.2.1
Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment

Sources: 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 White et al 2003;12 Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 201116

Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 1980–98,6-12 and from the National Drug Strategy Household Survey 2001–1013-16. See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as 'current smokers' (no frequency specified). Since 2001, the figures include those reporting that they smoke 'daily' or 'at least weekly'.

All data weighted to 2001 census population data and may vary slightly from data presented in the previous edition

* Includes persons smoking any combination of cigarettes, pipes or cigars

Figure 9.2.1 plots this data, omitting figures for those who left school before Year 10. (Given the historically lower minimum leaving age for school, and the historically lower rates of participation by women in tertiary education, this group would comprise mainly older people with varying levels of income and living in varying circumstances. Older populations also exclude people who have died prematurely due to smoking.)

Figure 9.2.1 would seem to indicate that smoking fell roughly equally among people of various educational levels between 1980 and 1992. Declines have flattened since the mid-1980s in less educationally qualified groups, but note the apparent fall in all groups between 1998 and 2001.iii Since 2004, declines have continued across all groups, with greater reductions in prevalence in the less-qualified and less-educated groups compared with university qualified. The pattern of these changes is discussed in more detail in Section 9.8.

9.2.1.2 Changes in prevalence in blue versus white collar groups

A quick reading of all the studies published on smoking prevalence in Australia over the past 30 years would seem to indicate that the gap in smoking prevalence between blue and white collar groups has widened considerably.17 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.

Table 9.2.2 sets out smoking prevalence between 1980 and 2010 for all occupational groups using data collected in surveys conducted by the Anti-Cancer Council of Victoria (now Cancer Council Victoria) until 1998, and then the National Drug Strategy Household Survey, both re-analysed to include just people 18 years and over.

Table 9.2.2
Prevalence of regular smokers in Australia aged 18+, 1980–2010: by occupational status

1980

1983

1986

1989

1992

1995

1998

2001

2004

2007

2010

drop

Reduction (%)

Upper white collar

32.5

28.1

24.0

22.7

19.7

19.0

18.1

16.0

14.0

12.9

13.4

18.5

57

Lower white collar

37.2

37.8

30.6

28.1

25.8

23.4

23.7

24.8

22.8

22.6

19.6

14.4

39

Upper blue collar

47.9

41.3

36.8

34.0

32.7

32.3

30.5

29.8

28.3

28.3

24.8

19.6

41

Lower blue collar

51.5

46.3

44.2

40.4

36.7

41.1

39.8

35.4

34.8

34.5

29.7

16.7

32

Not in paid work

27.0

30.5

27.3

25.0

24.6

24.1

25.3

20.6

20.8

17.6

18.9

6.20

23

Sources: 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 White et al 2003;12 Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 2011;16 Adhikari P and Summerill A 199918

Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 1980–986, 7,8,9-11,12 and from the National Drug Strategy Household Survey 1998–201013-16, 18. See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as 'current smokers' (no frequency specified). Since 2001 the figures include only reporting that they smoke daily or at least weekly.

Classifications changed in 2010 such that some occupations that would have been classed as upper blue in 2007 may be classified as lower blue in 2010. Tradespersons are classified as upper blue in 2010 but would have been classified as lower white in previous years.

All data weighted to 2001 census population data and may vary slightly from data presented in previous edition

* Includes persons smoking any combination of cigarettes, pipes or cigars

Figures 9.2.2

Figure 9.2.2
Prevalence of regular smokers in Australia aged 18+, 1980–2010, by occupational status

Source: Sources: 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 Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 2011;16 Adhikari P and Summerill A 199918

Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 1980–98 6, 7,8,9-11 and from the National Drug Strategy Household Survey 1998– 201013-16, 18. See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as 'current smokers' (no frequency specified). Since 2001 the figures include only reporting that they smoke daily or at least weekly.

Classifications changed in 2010 such that some occupations that would have been classed as upper blue in 2007 may be classified as lower blue in 2010. Tradespersons are classified as upper blue in 2010 but would have been classified as lower white in previous years.

Includes persons smoking any combination of cigarettes, pipes or cigars

All data weighted to 2001 census population data and may vary slightly from data presented in previous edition

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 more than halved over this study period (57%) while among lower blue collar workers, prevalence dropped by just over 30%. But is that the full story? Combining upper and lower blue collar groups and upper and lower white collar groups obscures some interesting differences between the four groups at various points of time.

Figure 9.2.2 sets out the data from Table 9.2.2, omitting the figures for those not in paid work.iv

Examining Figure 9.2.2, it is clear that smoking rates over the 1980s and early 1990s declined roughly equally in absolute terms among various occupational groups. Disparities appear to have widened briefly in the mid-1990s before the downward trend in smoking resumed in all four occupational groups.

It is also evident that one could get a very different picture of the relative declines among occupational groups in recent years depending on the period examined. Comparing 2010 with 1992 (showed by the dotted line in Figure 9.2.2), one would conclude that white collar groups did much better than blue. However comparing 2010 with 1995 (showed by the solid line), the decline would appear to be roughly equal, with a slight flattening in declines among upper white collar groups between 2007 and 2010. The implications of this pattern of decline are also discussed further in Section 9.8.

Figures 9.2.1 and 9.2.2 demonstrate the importance of avoiding simplistic point-in-time comparisons. Detailed statistical analysis is required to determine relative patterns of change over particular time periods.

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

Similar to the picture with occupational status, it is easy to see a significantly greater decrease in smoking prevalence among groups living in more advantaged compared with those living in less advantaged areas. This section provides analyses of smoking prevalence in males and females aged 18 years and older, by socio-economic index for areas (SEIFA).

Table 9.2.3
Percentage smokers in Australia and measures of absolute change and relative change, 2001–10, persons aged 18 years and over, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

25.5

30.5

29.2

27.2

2

7

SEIFA 2

27.9

25.9

23.5

22.2

–6

–20

SEIFA 3

26.4

23.5

21.7

18.7

–8

–29

SEIFA 4

24.5

19.3

18.4

16.9

–8

–31

SEIFA 5 (most advantaged)

19.4

16.6

15.4

13.4

–6

–31

Absolute difference between Q1 and Q5

6

14

14

14

Relative difference between Q1 and Q5

24

46

47

51

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years.

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.

Figure 9.2.3

Figure 9.2.3
Percentage smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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.

Between 2004 and 2010 smoking prevalence among adults declined significantly across all SEIFAs. The greatest declines between 2007 and 2010 were seen in SEIFAs 3 and 5.

Among males, significant declines in smoking prevalence were seen across all SEIFA groups with the exception of SEIFA 1, the most disadvantaged, where there was a significant increase in smoking prevalence (see Table 9.2.4 and Figure 9.2.4).

Among females, smoking prevalence declined significantly in all SEIFAs through the nine-year period 2001–10 (see Table 9.2.5 and Figure 9.2.5).

Table 9.2.4
Percentage smokers in Australia and measures of absolute change and relative change, males aged 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change 2001–10

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

27.3

31.4

30.7

29.0

2

6

SEIFA 2

29.9

27.5

26.1

23.7

–6

–21

SEIFA 3

28.3

26.5

22.2

20.1

–8

–29

SEIFA 4

27.2

21.3

21.3

19.8

–7

–27

SEIFA 5 (most advantaged)

22.7

18.6

16.7

14.3

–8

–37

Absolute difference between Q1 and Q5

5

13

14

15

Relative difference between Q1 and Q5

17

41

46

51

Source and notes: see Figure 9.2.4

Figure 9.2.4

Figure 9.2.4
Percentage smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years.

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.

Table 9.2.5
Percentage smokers in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

24.0

29.6

27.7

25.4

1

6

SEIFA 2

25.8

24.5

21.1

20.8

–5

–19

SEIFA 3

24.5

20.4

21.2

17.3

–7

–29

SEIFA 4

22.0

17.3

15.5

14.0

–8

–36

SEIFA 5 (most advantaged)

16.1

14.5

14.1

12.4

–4

–23

Absolute difference between Q1 and Q5

8

15

14

13

Relative difference between Q1 and Q5

33

51

49

51

Source and notes: see Figure 9.2.5

Figure 9.2.5

Figure 9.2.5
Percentage smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years.

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.

However, once again, such simplistic point-in-time comparisons obscure important differences between males and females in various categories of disadvantage. They also say little about the reliability of prevalence estimates given the quite small sample sizes that result from dividing the population into five groups.

But has the differential between SES groups increased over time?

Interestingly, the gradient of decline in female smoking prevalence is less pronounced across SEIFA groups. Smoking prevalence in the most advantaged group (SEIFA 5) declined less so than in SEIFA 3 and 4. In 2010, there was double the proportion of female smokers in SEIFA 1 than in SEIFA 5. However it reflects a fairly stable differential in smoking prevalence between SEIFAs 1 and 5 since 2004.

Similarly in males, the proportion of smokers in the least advantaged (SEIFA 1) was double that of those in the most advantaged group (SEIFA 5). The data show a slight pattern of widening disparity in prevalence between these groups over 2004–10.

9.2.2 Differential uptake or differential cessation?

In the population overall, smoking has reduced due to a combination of fewer people taking up smoking, more people quitting, and more smokers than non-smokers dying prematurely.

Table 9.2.6 and Figure 9.2.6 show the proportion of person who identified as never smokers, across SEIFA quintiles using data from the ABS National Drug Strategy Household Surveys between 2001 and 2010.

Table 9.2.6
Percentage never smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1(most disadvantaged)

45.4

43.4

45.7

49.6

4

9

SEIFA 2

43.9

46.4

50.1

53.1

9

21

SEIFA 3

46.5

48.8

54.0

54.5

8

17

SEIFA 4

47.5

53.6

54.4

57.2

10

20

SEIFA 5 (most advantaged)

52.6

54.3

56.9

60.5

8

15

Absolute difference between Q1 and Q5

–7

–11

–11

–11

Relative difference between Q1 and Q5

–16

–25

–25

–22

Source and notes: see Figure 9.2.6

Figure 9.2.6

Figure 9.2.6
Percentage never smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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 almost 50% in 2010. In comparison, almost 53% of those in the most advantaged group were never smokers in 2001 and this increased to 60.5% by 2010. The increase in never smokers in the most disadvantaged group was more modest compared to those of SEIFA 5 (most advantaged), as well as SEIFAs 2, 3 and 4. Although the proportion of the population who are never smokers has increased across all SEIFA groups, the gap between highest and lowest SEIFA appeared to widen between 2001 and 2007, with little evidence of any substantial narrowing between 2007 and 2010.

Table 9.2.7 and Figure 9.2.7 show the proportion of males who identified as never smokers, across SEIFA quintiles using data from the Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Surveys between 2001 and 2010.

Table 9.2.7
Percentage never smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

39.2

37.1

39.9

44.5

5

14

SEIFA 2

37.4

41.7

44.0

48.5

11

30

SEIFA 3

40.2

43.7

50.4

49.4

9

23

SEIFA 4

40.4

48.4

47.4

52.5

12

30

SEIFA 5 (most advantaged)

46.0

50.3

54.4

58.0

12

26

Absolute difference between Q1 and Q5

–7

–13

–15

–14

Relative difference between Q1 and Q5

–17

–36

–36

–30

Source and notes: see Figure 9.2.7

Figure 9.2.7

Figure 9.2.7
Percentage never smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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 data indicate that the proportion of males identifying as never smokers has increased between 2001 and 2010, across all SEIFA groups. The proportion of never smokers in SEIFA 5 in 2001 was 46%. This increased by 12% (in absolute terms) to 58% in 2010. In comparison, 39% of males in SEIFA 1 reported being never smokers in 2001; this increased by 5% (in absolute terms) to 44.5% in 2010.

However the proportions of never smokers are still substantially higher in the most advantaged group compared to the most disadvantaged group. The disparity between never smokers in the lowest and highest socio-economic group appears to have widened between 2001 and 2007, beyond this time it seems the disparity between the groups has narrowed little.

Table 9.2.8 and Figure 9.2.8 show the proportion of females who identified as never smokers, across SEIFA quintiles using data from the ABS National Drug Strategy Household Surveys between 2001 and 2010.

Table 9.2.8
Percentage never smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1

51.3

48.9

51.2

54.4

3

6

SEIFA 2

50.2

51.0

55.5

57.3

7

14

SEIFA 3

52.5

53.7

57.7

59.0

6

12

SEIFA 4

53.9

58.5

61.3

61.9

8

15

SEIFA 5

58.7

58.0

59.3

62.8

4

7

Absolute difference between Q1 and Q5

–7

–9

–8

–8

Relative difference between Q1 and Q5

–14

–19

–16

–15

Source and notes: see Figure 9.2.8

Figure 9.2.8

Figure 9.2.8
Percentage never smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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.

Proportions of never smoking in females have increased since 2001 across all SEIFA groups, with the most marked increase for women in SEIFA 4. The proportions of never smokers are still substantially higher in the most advantaged group compared to the least advantaged group. The disparity between the groups–although not having widened greatly since 2001–has, nevertheless, failed to narrow substantially during this period.

Table 9.2.9 and Figure 9.2.9 detail quitting patterns among adults across SEIFA quintiles. Again data from the AIHW's National Drug Strategy Household Surveys 2001–10 have been used in this analysis.

Table 9.2.9
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, persons 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

53

46

46

46

–7

–13

SEIFA 2

50

52

53

53

3

5

SEIFA 3

51

54

53

59

8

16

SEIFA 4

53

58

60

61

7

13

SEIFA 5 (most advantaged)

59

64

64

66

7

12

Absolute difference between Q1 and Q5

–6

–18

–18

–20

Relative difference between Q1 and Q5

–11

–38

–39

–44

Source and notes: see Figure 9.2.9

Figure 9.2.9

Figure 9.2.9
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, persons 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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 adults quitting smoking since 2001 has increased, most notably among SEIFAs 3, 4 and 5. The relative change in quitting has been modest among adults in SEIFA 2. In the most disadvantaged group, quitting behaviour decreased between 2001­ and 2004 and then remained stable, neither increasing nor decreasing over this time. Note the relative difference in quitting proportions between SEIFA 1 and SEIFA 5, with an indication of a widening disparity over the survey years.

Table 9.2.10 and Figure 9.2.10 show quitting patterns among males and females by socio-economic index for area.

Table 9.2.10
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, males 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

55.2

50.0

48.8

47.7

–7

–13

SEIFA 2

52.2

52.9

53.4

54.0

2

3

SEIFA 3

52.7

52.9

55.2

60.3

8

14

SEIFA 4

54.4

58.7

59.5

58.3

4

7

SEIFA 5 (most advantaged)

58.0

62.5

63.4

66.0

8

14

Absolute difference between Q1 and Q5

–3

–13

–15

–18

Relative difference between Q1 and Q5

–5

–25

–30

–38

Source and notes: see Figure 9.2.10

Figure 9.2.10

Figure 9.2.10
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, males 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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 Australian males, quitting behaviour shows no clear gradient across socio-economic groups between 2001 and 2010. An increase in the proportion of quitters is evident across all SEIFAs, with the exception of the most disadvantaged, SEIFA 1. The data on quitting habits in males indicate a growing differential between the most advantaged and least advantaged socio-economic groups.

Table 9.2.11 and Figure 9.2.11 show quitting patterns among females by socio-economic index for area.

Table 9.2.11
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area

2001

2004

2007

2010

Absolute change

Relative change

Socio-economic index for area (SEIFA)

%

SEIFA 1 (most disadvantaged)

50.6

42.0

43.2

44.3

–6

–12

SEIFA 2

48.2

49.9

52.6

51.4

3

7

SEIFA 3

48.4

55.9

49.9

57.9

9

20

SEIFA 4

52.3

58.2

59.9

63.3

11

21

SEIFA 5 (most advantaged)

60.9

65.6

65.4

66.7

6

9

Absolute difference between Q1 and Q5

–10

–24

–22

–22

Relative difference between Q1 and Q5

–20

–56

–51

–50

Source and notes: see Figure 9.2.11

Figure 9.2.11

Figure 9.2.11
Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012.

Note: 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.

In females, the proportion quitting among the most advantaged group is less than among their male counterparts. Again, there is not a strong gradient in quitting behaviour across all SEIFAs, although every SEIFA except SEIFA 1 had an increase in quitting behaviour between 2001 and 2010. The social gradient in quitting proportions between the most advantaged and least advantaged females is less pronounced than in males; however the gap between these groups has not lessened over this period.

Interestingly, in data collected on Victorian adult smoking prevalence over a 25-year period, researchers reported that population-wide strategies such as tax increases, mass media campaigns and smokefree policies may have been just as influential on those in low socio-economic groups as among those in high socio-economic groups. They found that in the period 1984–2008, adults in the lowest socio-economic groups experienced greater relative increases in quitting proportions (75%) than those in high socio-economic groups (50%) and mid-socio-economic groups (37%). Those in the lower-to-mid socio-economic groups also had the greatest rates of decline in ever smoking over the 25-year period in comparison to the most advantaged groups.19

In 2010, 81% of regular smokers in Victoria reported making at least one quit attempt during their lifetime. This represented a relative increase of 7% from 1998, where the proportion of regular smokers who had made at least one quit attempt was 76%. Significant linear increases in the proportions of regular smokers who had ever made a quit attempt were seen in the low and mid socio-economic groups, but significant increases were not seen in the most advantaged socio-economic group. There was also a significant increase in the proportion of regular smokers making multiple quit attempts (defined as three or more attempts), from 37% in 1998 to 49% in 2010. This appears related to downward trends in the proportion of regular smokers who had made one or two attempts, and those who had never attempted to quit smoking. 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.20

Vangeli and colleagues conducted a systematic review of literature to distinguish predictors of quit attempts and quitting success among adult general population samples. The studies examined were methodologically diverse, but suggested past quit attempts and motivational factors were highly predictive of quit attempts, and cigarette dependency was consistently predictive of a successful quit attempt. Socio-economic status appeared to be predictive of success (note, however, it was examined in only two of the studies). Other demographic factors–gender, age, marital status and educational level–were not consistently connected with quit attempts or quitting success across the countries examined.21

9.2.3 Changes in consumption of cigarettes

Table 9.2.12 illustrates consumption levels among smokers of varying occupational classes. Declines in consumption were considerable in upper white collar, lower white collar and upper blue collar groups, yet consumption among the lower blue collar group actually increased across this period.

Table 9.2.12
Self-reported cigarettes smoked (number per week) by Australian adult smokers (factory-made cigarettes only), 1980–2010, by occupational class

Year

Lower blue collar

Upper blue collar

Lower white collar

Upper white collar

Not in labour force

1980

144.9

141.4

129.5

131.6

131.6

1983

168.7

147.7

140.0

163.8

149.1

1986

161.0

149.8

138.6

157.5

147.0

1989

167.3

163.8

151.2

165.9

162.4

1992

148.4

156.1

122.5

140.0

151.2

1995

137.2

140.7

118.3

133.0

137.2

1998

134.4

144.2

114.1

138.6

136.5

2001*

140.6

123.7

109.1

105.7

134.4

2004

134.9

119.7

103.8

104.8

133.1

2007

132.8

121.4

105.4

101.1

133.5

2010

148.0

115.2

104.8

97.6

135.5

% change 1980–2010

+2

19

19

26

+3

% change 2001–10

+5

7

4

8

+1

Source: Australian Institute of Health and Welfare 2001,13 2004,142007,15 201016

* Consumption assessed using a different method in 2001 to that used in later years.

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 appear to have been even more significant than lower levels of cessation as a driver of socio-economic disparities in smoking in Australia.v To assess the likelihood of increasing disparity in the future, researchers could more carefully analyse rates of never smoking and cessation among different SES groups in cohorts of adults born since 1970.

Data on smoking rates among secondary school students of different socio-economic backgrounds provide some indication of what future smoking disparities by SES
may be.

Information on socio-economic backgrounds of students is not collected in surveys of youth smoking in Australia. Figures 9.2.12 and 9.2.13 show smoking rates among young people aged 16 and 17 years and 12–15 years between 1987 and 2008 according to the level of disadvantage of the neighbourhood in which they lived.

Figure 9.2.12

Figure 9.2.12
Reported current smoking (smoking in the last week), secondary students in Australia aged 16 and 17 years, 1987–2008, ranked by quartiles of advantage by the area in which the student lived

Sources: White, Hayman and Hill 200823, Table 2; and data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council, April 2012, by V White, Centre for Behavioural Research in Cancer, Cancer Council Victoria

Figure 9.2.13

Figure 9.2.13
Reported current smoking (smoking in the last week), secondary students in Australia aged 12–15 years, 1987–2008, ranked by quartiles of advantage by the area in which the student lived

Sources: White, Hayman and Hill 200823, Table 2; and data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council, April 2012, by V White, Centre for Behavioural Research in Cancer, Cancer Council Victoria

Declines in student smoking rates have been substantial across all quartiles since the late nineties and early 2000s, with the exception of students living in the lowest socio-economic area, where declines there have been more modest.

Interestingly, a sharp decline in smoking was evident across the period 1987–2005 among students living in the most advantaged areas; however declines in this group have appeared to flatten in the three years to 2008. By 2008, smoking rates in students living in the third, second and lowest areas of advantage were lower than the smoking rates of students in the most advantaged areas.

Following a sharp reversal of the socio-economic gradient among young people aged 12–15 years between 1990 and 1996, between 1996 and 2008 smoking declined roughly equally among students at all levels of disadvantage, however again a flattening in smoking prevalence is apparent between 2005 and 2008 for those living in the highest quartile, so that there is only small variation in smoking rates between the groups at 2008.

9.2.5 Changes in childhood exposure to smoking in the household

In 2010, 77% of the most disadvantage households with dependent children where at least one person was a smoker smoked only outdoors. The proportion of outdoor-only smoking in this group rose by 50% from 2001. In 2010, 90.4% of the most advantaged households containing dependent children smoked only outdoors (see Table 9.2.13).

Table 9.2.13
Percentage of households who reported smoking only outdoors in the last 12 months, Australia, 2001, 2004, 2007 and 2010, socio-economic index for areas: households with dependent children

Year

%
change between 2001 and 2010

2001

2004

2007

2010

Quintile

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

95% CI

Lowest

51.5

(46.1–56.9)

56.6

(52.2–61.0)

72.3

(67.1–77.4)

77.4

(72.9–81.8)

50.2

(32.3–68.1)

Second

50

(45.7–54.3)

66.8

(62.7–70.9)

78.3

(73.1–83.5)

87.1

(83.2–90.9)

74.1

(57.2–91.1)

Third

57.6

(52.1–63.0)

76.2

(72.5–80.0)

80.9

(76.0–85.9)

84.9

(80.6–89.1)

47.4

(31.6–63.1)

Fourth

58.8

(52.5–65.0)

72.3

(68.1–76.4)

82.3

(77.3–87.2)

91

(87.6–94.4)

54.9

(37.5–72.3)

Highest

67.2

(61.3–73.2)

80.8

(76.0–85.5)

81.3

(74.7–87.9)

90.4

(85.8–95.0)

34.4

(20.7–48.2)

Gap lowest to highest

15.7*

(7.7–23.7)

24.2

(17.7–30.6)

9.1*

(0.7–17.4)

13.0*

(6.6–19.5)

Source: Gartner and Hall 201224

* Result should be interpreted with caution because Relative Standard Error lies between 25% and 50%.

Gartner and Hall examined trends in the social gradient of children's exposure to secondhand smoke in Australian households between 2001 and 2010. They found that exposure of children to tobacco smoke in the home decreased substantially over the decade, except in the case of the most disadvantaged households, where about half of households with a child still contained at least one smoker. On this measure, their research showed the disparity between household secondhand smoke exposure in children had increased between the least advantaged and most advantaged households.24

Sims and colleagues collected data on secondhand smoke exposure in children (measured by mean cotinine levels) in England between 1996 and 2006. Children from more deprived households were most exposed, however across the 11-year research period secondhand smoke exposure in children declined substantially, with a 59% decline in geometric mean cotinine levels over this time. 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.25

9.2.6 International comparisons

Observations of smoking and its connection with socio-economic disadvantage and widening disparities between the most and least advantaged social classes 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 proportions of smokers between these groups. It reported smoking as nearly twice as common in routine and manual households as in managerial and professional households (28% compared to 15%). The authors noted the 'striking' differences between various social classes. 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.26

Observations on adult smoking and emerging disparities between social classes have been made in research out of New Zealand,27 Italy,28 the US and Canada29–31and France.32

i Participation rates in Year 12, for instance, increased from 45% in 1984 to 76% in 2009.2

ii For data for males and females to 2007, refer to Chapter 1, Table 1.7.1.

iii As discussed in Section 9.8, this was the period in Australia when the National Tobacco Campaign was most active and reforms of taxes on cigarettes resulted in very large price rises in budget brands.

iv While the 'not in paid work' category is likely to include a proportion of socio-economically disadvantaged people, who as a demographic group demonstrate a higher prevalence of smoking, this category also includes retired people (older people being less likely to smoke than younger people–Table 1.4), those engaged in domestic duties (more likely to be female than male, and hence to have a lower smoking prevalence–Table 1.2), and students in post-secondary education (who are less likely to be smokers than those with a lower level of education level–Table 1.6).

v An analysis of generational trends in the UK similarly found that while rates of uptake were higher among manual workers than non-manual workers, manual workers born before 1950 were equally as likely to give up smoking as non-manual workers born before 1950.22

References

1. Zhu S, Hebert K, Wong S, Cummins S, and Gamst A. Disparity in smoking prevalence by education: can we reduce it? Global health promotion. 2010;17(suppl. 1):29–39. Available from: http://ped.sagepub.com/content/17/1_suppl/29.full.pdf+html

2. Australian Bureau Statistics. 6278.0 Education and Training Experience. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/6278.0

3. Australian Bureau of Statistics. 1370.0 - Measures of Australia's progress, 2010. Canberra: ABS, 2010. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/1370.0

4. Australian Bureau of Statistics. 4221.0 Schools, Australia 2011. Canberra: ABS, 2012. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4221.0

5. Australian Bureau of Statistics. 4102.0 - Australian Social Trends, March quarter, 2012. Canberra: ABS, 2012. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4102.0

6. Hill D, and Gray N. Patterns of tobacco smoking in Australia. Medical Journal of Australia. 1982;1(1):23–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7062879

7. Hill D, and Gray N. Australian patterns of smoking and related health beliefs in 1983. Community Health Studies. 1984;8(3):307–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/6518750

8. Hill D. Australian patterns of tobacco smoking in 1986. Medical Journal of Australia. 1988;149(1):6–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3386578

9. Hill D, White V, and Gray N. Australian patterns of tobacco smoking in 1989. Medical Journal of Australia. 1991;154(12):797–801. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2041504

10. Hill D, and White V. Australian adult smoking prevalence in 1992. Australian Journal of Public Health. 1995;19(3):305–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7626682

11. Hill DJ, White VM, and Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Medical Journal of Australia. 1998;168(5):209–13. Available from: http://www.mja.com.au/public/issues/mar2/hill/hill.html

12. White V, Hill D, Siahpush M, and Bobevski I. How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001. Tobacco Control. 2003;12(suppl. 2):ii67-74. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/12/suppl_2/ii67

13. Australian Institute of Health and Welfare. 2001 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 11, AIHW cat. no. PHE 41. Canberra: AIHW, 2002. Available from: http://www.aihw.gov.au/publications/index.cfm/title/8227

14. Australian Institute of Health and Welfare. 2004 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 16, AIHW cat. no. PHE 66. Canberra: AIHW, 2005. Available from: http://www.aihw.gov.au/publications/phe/ndshsdf04/ndshsdf04.pdf

15. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 22, AIHW cat. no. PHE 107. Canberra: AIHW, 2008. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10674

16. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: survey report. Drug statistics series no 25, AIHW cat. no. PHE 145. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712

17. Smith DR. Tobacco smoking by occupation in Australia and the United States: a review of national surveys conducted between 1970 and 2005. Industrial Health 2008;46:77-89. Available from: http://www.jstage.jst.go.jp/article/indhealth/46/1/46_77/_article

18. Adhikari P, and Summerill A. 1998 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 6, AIHW cat. no. PHE 27. Canberra: Australian Institute of Health and Welfare, 1999. Available from: http://www.aihw.gov.au/publications/index.cfm/title/6243

19. Germain D, Durkin S, Scollo M, and Wakefield M. The long-term decline of adult tobacco use in Victoria: changes in smoking initiation and quitting over a quarter of a century of tobacco control. Australian and New Zealand Journal of Public Health. 2012;36(1):17-23. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00805.x/full

20. Centre for Behavioural Research in Cancer. Current and former smokers' quitting activity and intentions: findings from the 1998-2010 Victorian Smoking and Health Surveys, unpublished data. Melbourne, Australia: CBRC, 2011.

21. Vangeli E, Stapleton J, Smit ES, Borland R, and West R. Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review. Addiction. 2011;106(12):2110-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21752135

22. Davy M. Socio-economic inequalities in smoking: an examination of generational trends in Great Britain. Health Statistics Quarterly. 2007(34):26–34. Available from: http://www.statistics.gov.uk/articles/hsq/HSQ34_Smoking.pdf

23. White VM, Hayman J, and Hill DJ. Can population-based tobacco-control policies change smoking behaviors of adolescents from all socio-economic groups? Findings from Australia: 1987–2005 Cancer Causes & Control. 2008;19(6):631–40. Available from: http://www.springerlink.com/content/x1h33x711616h254/

24. Gartner CE, and Hall WD. Is the socioeconomic gap in childhood exposure to secondhand smoke widening or narrowing? Tobacco Control. 2012; [Epub ahead of print] . Available from: http://www.ncbi.nlm.nih.gov/pubmed/22467710

25. Sims M, Tomkins S, Judge K, Taylor G, Jarvis MJ, and Gilmore A. Trends in and predictors of second-hand smoke exposure indexed by cotinine in children in England from 1996 to 2006. Addiction. 2010;105(3):543–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20402999

26. Robinson S, and Harris H. Smoking and drinking among adults, 2009. A report on the 2009 General Lifestyle Survey. London: Office of National Statistics, 2011. Available from: http://www.ons.gov.uk/ons/rel/ghs/general-lifestyle-survey/2009-report/index.html

27. Barnett R, Pearce J, and Moon G. Community inequality and smoking cessation in New Zealand, 1981–2006 Social Science & Medicine. 2009;68(5):876–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19136183

28. Federico B, Costa G, Ricciardi W, and Kunst AE. Educational inequalities in smoking cessation trends in Italy, 1982-2002. Tobacco Control. 2009;18(5):393-8. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/5/393

29. Chilcoat HD. An overview of the emergence of disparities in smoking prevalence, cessation, and adverse consequences among women. Drug and Alcohol Dependence. 2009;suppl. 1:S17-23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19632070

30. Reid J, Hammond D, and Driezen P. Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use? Canadian Journal of Public Health. 2010;101(1):73–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20364543

31. Smith P, Frank J, and Mustard C. Trends in educational inequalities in smoking and physical activity in Canada: 1974 to 2005. Journal of Epidemiology and Community Health. 2009;63(4):317–23. Available from: http://jech.bmj.com/content/63/4/317.long

32. Peretti-Watel P, Constance J, Seror V, and Beck F. Cigarettes and social differentiation in France: is tobacco use increasingly concentrated among the poor? Addiction. 2009;104(10):1718–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19681803

      Previous Chapter Next Chapter