9.3 Contribution of smoking to health inequality

As is the case elsewhere in the world, ill-health and rates of premature death in Australia show a clear gradient across socio-economic status (SES) groups.1–3

People who are poorer or disadvantaged in other ways generally suffer more illness and reduced quality of life and die earlier than people who are better off. The social gradient holds regardless of how socio-economic disadvantage is measured.1

People who are disadvantaged are more likely to live with multiple risks to their health. Lower socio-economic status is associated with higher rates of obesity, lack of adequate physical activity and diabetes–especially so among Indigenous communities.1,2,4

However, with or without such additional risk factors, current smokers are much less likely than non-smokers to be in good health and the incidence of numerous diseases is significantly higher among smokers and recent ex-smokers than among long-time ex-smokers and never smokers.5,6

Social differentials in smoking during pregnancy, smoking prevalence, cigarette consumption, duration of smoking and exposure to environmental tobacco smoke must contribute substantially to socio-economic differentials in health status and mortality.

This section outlines data on relative rates of poor health, disease, mortality and life expectancy across SES groups, and also presents estimates of the contribution of smoking to these health disparities.

9.3.1 Socio-economic position, reported health status and smoking

People who live in disadvantaged areas are much less likely to assess their own health as excellent or good.1, 2

Data from Australian national surveys commonly report higher rates of arthritis, chronic respiratory disease, cardiovascular disease and depression in least advantaged groups in comparison to more advantaged groups in the population.2,7–9 The rates of profound disability and type 2 diabetes in low socio-economic areas are double that of those in the highest socio-economic areas.2

In 2010, only 41% of smokers participating in the National Drug Strategy Household Survey reported their overall health as 'very good' or 'excellent', compared to 50% of ex-smokers and almost 60% of non-smokers. Ex-smokers were more likely to report diagnoses or treatment for heart disease and cancer than smokers and non-smokers. Smokers were more likely to report asthma, and twice as likely as non-smokers to have been diagnosed with, or treated for, mental illness.10

9.3.2 Socio-economic position and illnesses known to be caused by smoking

Hospitalisations for cardiovascular disease show a clear socio-economic gradient. In 2003–04 rates of hospitalisations for males in the most disadvantaged socio-economic group were 1.3 times those of males of least socio-economic disadvantage. The hospitalisation rate for the most disadvantaged females was higher again, with rates 1.4 times that of females in the least disadvantaged socio-economic group. A socio-economic gradient is evident for other chronic diseases for which smoking is a risk factor, with hospitalisations for coronary heart disease and stroke among males and females increasing as socio-economic status decreases.11

The Australian Institute of Health and Welfare has estimatedi that lung cancer was the fourth leading cause of disease among males and the seventh leading cause of disease among females in 2011. Lung cancer incidence is disproportionately high in those of lower socio-economic status in Australia, with increasing incidence of lung cancer associated with decreasing socio-economic status, across the five years 2003–2007. In the year 2008–09, the rate of hospitalisations for lung cancer was higher for those living in the lowest socio-economic areas of Australia. Those living in the lowest socio-economic areas were hospitalised for lung cancer at 1.5 times the rate of those living in areas of highest socio-economic advantage.12

Chronic kidney disease has increasingly been shown to be connected with smoking and cardiovascular disease.13, 14 It is more common in low socio-economic groups and particularly so among Indigenous Australians.2, 14

Between 2000–01 and 2007–08, hospitalisations for chronic kidney disease were highest for Australians living in the most disadvantaged areas. Hospitalisations for kidney dialysis among the lowest socio-economic group were 1.6 times the rate of those in the most advantaged group. After removing the rates for regular dialysis from all chronic kidney disease-related hospitalisations, the rates of hospitalisations among the lowest socio-economic group remained almost twice that of the most advantaged group.15

The worsening of asthma symptoms is known to be associated with active smoking and/or exposure to secondhand smoke. Smoking and asthma are both more common in those living in low socio-economic areas. The Australian Centre for Asthma Monitoring (a collaborating unit of the Australian Institute of Health and Welfare) reported that in 2007–08, not only was asthma much more common among those living in the most deprived socio-economic areas in Australia, but that rates of smoking among asthmatics in low socio-economic areas were far higher than for asthmatic smokers living in areas of higher socio-economic status (37.8% and 12.9% respectively). The disparity between the lowest and highest socio-economic group in asthma prevalence was found to have widened between survey years 2004–05 and 2007–08.16

9.3.3 Socio-economic disparities in death rates from diseases known to be caused by smoking

Australians from lower socio-economic groups have a greater proportion of chronic disease mortality burden than those living in more advantaged areas.17 This sub-section presents information on socio-economic disparities in mortality rates from diseases associated with smoking, however it is important to note the influence and interplay of other health risk factors and social and economic deprivation across a life-course, in the contribution to disease and premature mortality among the disadvantaged. Section 9.3.5 provides a detailed discussion on quantifying the contribution of smoking to socio-economic differentials in heath status; associations between childhood circumstances and health outcomes, smoking and intergenerational poverty are discussed further in Section 9.5.

The potential years of life lost (PYLL)ii due to cancer deaths in 2007 was greater among Australians living in the most disadvantaged areas (55%) compared with those living in the least disadvantaged areas (42%). A gradient across socio-economic groups was evident for cardiovascular disease, chronic respiratory disease, digestive diseases and diabetes, whereby the proportion of PYLL due to premature mortality from these diseases were represented more highly in those living in lower socio-economic areas.17

According to data compiled by the Public Health Information Development Unit in South Australia, a strong economic gradient was evident for premature mortality associated with lung cancer, with more avoidable lung cancer deaths in the most disadvantaged areas (25.9 per 100 000) compared with those in the least disadvantaged areas (15.2 per 100 000) between 2003 and 2007.18

Similar trends of a disproportionate level of mortality burden being borne among those of less socio-economic advantage have been observed in international studies.

A 24-year study of British men and women examined the relationship between socio-economic status and mortality, and the influence smoking, alcohol consumption, diet and physical activity have on mortality. In terms of all-cause mortality, those of lowest socio-economic position had 1.6 times the risk of death in comparison with those of higher socio-economic position. There was also a graded association for cardiovascular disease mortality and socio-economic position. Health risk behaviours, including smoking, were connected with mortality.19

Studies of cancer mortality in the US show disparities related to socio-economic position and also to ethnicity.20,21

9.3.4 Socio-economic disparities in health-adjusted life expectancy

As part of research on preventable causes of disease conducted for the Australian Government, researchers at the University of Queensland examined differentials in the burden of disease across socio-economic groups.6

At birth, those in the lowest socio-economic quintile could expect to die at least three years earlier than those in the highest economic quintile (79.6 compared with 82.7 years). Adjusting for ill-health, those in the lowest quintile could expect to live four years less than those in the highest quintile. By the age of 60, those in the lowest quintile could expect 15% fewer years of health-adjusted life than those in the highest quintile (Table 9.3.1).

Table 9.3.1
Life expectancy, Australia, 2003, by socio-economic quintile


Life expectancy at birth (years)

Health-adjusted life expectancy at birth (years)

Health-adjusted life expectancy at age 60 (years)

Life expectancy at birth lost due to disability (%)

Socioeconomic quintile


79.6 (79.4–79.7)




Moderately low

80.0 (79.9–80.2)





80.2 (80.0–80.3)




Moderately high

81.2 (81.1–81.4)





82.7 (82.5–82.8)




Difference between lowest and highest (%)





Source: Begg et al 20076

Researchers estimated that, for the year 2003, a total of 2 632 800 disability-adjusted life years (DALYS) were lost in Australia. DALYs were calculated for each of the five socio-economic quintiles (Table 9.3.2).

Table 9.3.2
Disability-adjusted life years lost, Australia, 2003, by socio-economic quintile, Australia, 2003


DALYs ('000)

% of total

Socioeconomic quintile




Moderately low






Moderately high







2 632.8


Source: Begg et al 20076

DALY = disability-adjusted life year

After adjusting for age, loss rates were 31.7% higher in the lowest SES quintile than in the highest.6 Rates of burden were higher for most causes, but particularly for mental disorders and cardiovascular disease. Per head of population, rates of burden were 26.5% higher in remote areas than in major cities.3, 6

Life expectancy among Indigenous Australians is discussed in Chapter 8.

In the US, researchers examined the effects of a number of health risk factors, including smoking, on life expectancy and disparities in life expectancy in eight sub-groups of the population. Individually, smoking and high blood pressure had the most profound effect on life expectancy disparities. They found that variation of life expectancies in the eight sub-groups would decline by 18% in men and 21% in women if the health risks (smoking, blood pressure, elevated blood glucose, and adiposity or obesity) had been reduced to optimal levels.22

The Whitehall study followed more than 18 000 English males over a period of 38 years to examine life expectancy in relation to cardiovascular risk factors, which were recorded at middle age. The study reported that the presence of all three risk factors (smoking, high blood pressure and high cholesterol) at baseline (middle-age) predicted a three-fold rate of vascular mortality and about a 10-year reduced life expectancy from age 50 years, when compared with men who had none of the risk factors present at the commencement of the study.23

9.3.5 Quantifying the contribution of smoking to socio-economic differentials in health status

Estimates of the contribution of smoking to social inequality vary, likely due to differences in study methodology and datasets. Estimates may also be affected by declines in smoking prevalence in developed countries, changing social demographics, latency of disease and death associated with smoking, and the emergence of other risk factors and their contribution to disease and mortality. This section presents research across time and using differing methods to quantify the contribution of smoking to health inequalities. Section 9.3.6 explores whether the inequalities in health outcomes and life expectancy are widening.

In the UK, Jarvis and Wardle used an 'indirect method' to estimate that tobacco caused about two-thirds of the difference in risk of death across social class in men age 35–69 years.24 Prabhat Jha and colleagues reported in a four-country study (England, Wales, Poland and North America) that most social inequalities in adult male mortality during the 1990s were due to smoking.25

Bobak and colleagues reported similar results for Canada, Poland and the US, and contended that eliminating smoking would halve the social gradient in mortality among men.26 Professor Sir Michael Marmot, a public health epidemiologist and expert in health inequality, has been critical of these sorts of estimates, because some estimates have been derived by using lung cancer mortality as a proxy measure for smoking exposure, rather than using crude estimates to determine the contribution of smoking to socio-economic differences in mortality; hence they are likely to overestimate the importance of smoking.27 Authors of these studies have generally acknowledged the limits of indirect estimation.

Blakely and Wilson and colleagues used direct methods to estimate the contribution of smoking to socio-economic and ethnic inequalities in mortality in New Zealand. Between 1996 and 1999, smoking contributed 21% to the gap between men aged 45–74 years with post-school qualifications and those with none. The corresponding figure for women was 11%.28 But other work suggested that only 5–10% of the larger inequality in mortality between Māori and non-Māori individuals was due to smoking, despite large differences in smoking prevalence.29 This estimate contrasted with a much greater estimated contribution by the Ministry of Health using Jha and colleagues' indirect method.30

A study by Siahpush, English and Powles31 estimated that in Australia, smoking could account for just over one-third of the excess deaths in the 1990s that would otherwise be attributed to lower levels of education. Data on deaths among men aged 40–69 years taking part in a prospective cohort study in Melbourne between 1990 and 1994 showed that the association between education and mortality was greatly weakened after adjustment for smoking and the aetiologic fraction for low level of education was reduced from 16.5% to 10.6%.

Vallejo and colleagues used data from the National Health Survey for England to estimate the contribution of lifestyle factors–obesity and smoking–to health inequalities across social classes (classified by level of income). Their findings, released in 2010, show income as a significant contributor to health inequalities, and that obesity and smoking contribute significantly, but less profoundly, to income-related inequalities in health. Obesity and smoking were estimated to contribute 1.2% and 3.2% to inequality respectively. Despite the prevalence of smoking declining over time, its effects on inequalities have slightly increased because of its over-representation among the lowest socio-economic groups and its effects on health.32

It is likely that indirect estimates of the contribution of tobacco smoking overestimate the importance of smoking by failing to take account of higher-than-average prevalence of behavioural and other risk factors in low-SES populations. Direct methods, however, may underestimate the importance of smoking because they do not take into account the long-term impact of smoking during pregnancy and the impact of smoking and exposure to tobacco smoke on diseases other than the ones for which epidemiological data are readily available. They also may not take account of the effects of spending on tobacco products on financial security and intergenerational poverty, which may help to perpetuate continuing high smoking rates in the children of smokers. These issues are explored further in Sections 9.4 to 9.8.

Thun also discusses the difficulties in directly quantifying the contribution of smoking to disparities across social classes in a review of a study by Menvielle and colleagues,33 whose work estimated the degree to which smoking contributes to social class differences (classified by education level) in lung cancer incidences across a cohort of individuals from 10 European countries. Menvielle and colleagues concluded that smoking could account for about 50% of the inequalities in lung cancer risk due social group disparities in education. They noted these findings were unusual, and suggest residual confounding by smoking. They noted that in future studies, other risk factors in relation to smoking should be considered. Thun expressed the complexity in quantifying a direct relationship in this study because of changing demographics in Europe–the relationship between social class, smoking and lung cancer incidences have evolved and changed over time–noting, 'it is extremely difficult for Menvielle et al. to disentangle the historical and birth cohort effects of lifetime smoking on lung cancer risk from any other factors that may have contributed to risk'.34

9.3.6 Are tobacco-related differentials in health status widening?

In the US the socio-economic gap in life expectancy appears to be worsening. In people who had more than 12 years of education, life expectancy in the 1990s was about a year and a half greater than it was in the 1980s. In less educated people, life expectancy increased by only half a year. Much of the growing mortality gap can be attributed to the higher levels of decline in smoking-related diseases such as lung cancer and chronic obstructive pulmonary disease in more advantaged groups.35 Study authors attribute this to the larger declines in smoking prevalence in more advantaged compared with less advantaged groups that have been evident for some time in the US. Irvin and colleagues reported in 2009 that great disparities among socio-economic groups as well as racial groups exist for tobacco-related cancer incidences and mortality in the US. Disparities also 'exist in access to, and quality of, cancer treatment'.36

The situation for Australia is much less clear-cut.

A study published by the Australian Institute of Health and Welfare in 2006 indicated that death rates for cardiovascular disease reduced in all socio-economic groups between 1999 and 2003. There was a decrease in the size of the gap between the rates of death between upper and lower socio-economic groups for coronary heart disease and cardiovascular disease as a whole but an increase in the relative effect of disadvantage (the proportion by which the lowest socio-economic group was higher than the highest socio-economic group) for coronary heart disease, stroke and cardiovascular disease as a whole.11

In 2011, the Australian Institute of Health and Welfare reported death rates from cardiovascular disease have continued falling (based on AIHW mortality data from 2007). However, those of lower socio-economic status, the Indigenous and those living in remote areas of Australia still had the highest rates of hospitalisations and death from cardiovascular disease.37

Between 1982 and 2007, the age standardised mortality rates for lung cancer among Australian males decreased significantly, whereas mortality rates among females increased across this period. This trend is indicative of past smoking patterns. Lung cancer mortality rates for males peaked in the early 1980s, and since this time, have declined substantially; a reflection of declining smoking rates in males in the second half of the 20th century. In the case of women, females took up smoking later in the 20th century (increasing since the mid-1940s and reaching prevalence of about 33% in the mid–1970s), yet they smoked less than males. This pattern is reflected in female lung cancer mortality rates. These have been increasing over time, but more recently in the 1990s and 2000s, the increase has slowed compared with decades prior. Mortality rates from lung cancer show a clear social gradient. For the period 2003–2007, the highest mortality rates for all persons were among those living in the most disadvantaged areas in Australia. The mortality rate for males living in the least advantaged areas was 1.5 times the rate of mortality for males living in the most advantaged areas. Among females, the gap was slightly less, with 1.3 times the mortality rate in females living in the least advantaged areas compared with females living in the most advantaged areas.12 No data could be located on whether or not disparities in lung cancer mortality have widened.

Between 1979 and 2006, mortality rates between low-SES groups and high-SES groups have narrowed in absolute terms among females for ischaemic heart disease (27 to 23 per 100 000). However, absolute differences for ischaemic heart disease widened in males across this period (52 to 63 per 100 000). Absolute differences for stroke between low and high-SES groups declined in males and females (16 to 13 per 100 000 among males and 13 to 7 per 100 000 among females).

However relative declines were greater in high socio-economic groups compared with low socio-economic groups for both ischaemic heart disease (28% average five yearly decline in high socio-economic status males compared with 21% in low-SES males, and 30% and 21% for females respectively). For stroke, there was a 25% average five yearly decline in high-SES males compared with 21% in low-SES status males; 26% and 23% for females respectively).38

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i Estimate projected from a 2003 baseline, derived from AIHW Burden of Disease database, see table 7.1. (p.70)12

ii Potential years of life lost (PYLL): 'an indicator of premature death. PYLL are determined by age at death and takes in to account only deaths that occur before a particular age'.17


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2. Australian Institute of Health and Welfare. Australia's health 2010. Australia's health series no 12, AIHW cat. no. AUS 122. Canberra: AIHW, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468376&tab=2

3. Begg S, Vos T, Barker DC, Stanley L, and Lopez A. Burden of disease and injury in Australia in the new millenium: measuring health loss from diseases, injuries and risk factors. Medical Journal of Australia. 2007;188(1):36-40. Available from: http://www.mja.com.au/public/issues/188_01_070108/beg10596_fm.html

4. Australian Institute of Health and Welfare. Health determinants, the key to preventing chronic disease. AIHW cat no PHE 157. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737421466&tab=2

5. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm

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11. Moon L, and Waters A. Socioeconomic inequalities in cardiovascular disease in Australia. AIHW Bulletin no. 37. Canberra: Australian Institute of Health and Welfare, 2006. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10307

12. Australian Institute of Health and Welfare, and Cancer Australia. Lung cancer in Australia: an overview. Cancer series no 64, AIHW cat. no. CAN 58. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420419&tab=2

13. Orth SR, and Hallan SI. Smoking: a risk factor for progression of chronic kidney disease and for cardiovascular morbidity and mortality in renal patients-absence of evidence or evidence of absence? Clinical Journal of the American Society of Nephrology. 2008;3(1):226-36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18003763

14. Australian Institute of Health and Welfare. Chronic kidney disease in Australia 2005. AIHW cat. no. 65. Canberra: AIHW, 2005. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10137

15. Australian Institute of Health and Welfare. Chronic kidney disease hospitalisations in Australia 2000-01 to 2007-08. AIHW cat. no. PHE 127. Canberra: AIHW, 2010. Available from: http://www.aihw.gov.au/ckd-publications/

16. Australian Centre for Asthma Monitoring. Asthma in Australia 2011. Asthma series no.4. AIHW cat. no. ACM 22. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159&libID

17. Australian Institute of Health and Welfare. Premature mortality from chronic disease. AIHW bulletin no 84, Cat. no. AUS 133. Canberra: AIHW, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442472466&tab=2

18. Public Health Information Development Unit. Monitoring Inequality in Australia, 2010. South Australia, Australia: The University of Adelaide, 2010. [viewed 7 May 2012] . Available from: http://www.publichealth.gov.au/inequality-graphs/monitoring-inequality-in-australia-australia-2010.html

19. Stringhini S, Sabia S, Shipley M, Brunner E, Nabi H, Kivimaki M, et al. Association of socioeconomic position with health behaviors and mortality. Journal of the American Medical Association. 2010;303(12):1159–66. Available from: http://jama.ama-assn.org/cgi/content/full/303/12/1159

20. Ou S, Ziogas A, and Zell J. Prognostic factors for survival in extensive stage small cell lung cancer (ED-SCLC): the importance of smoking history, socioeconomic and marital statuses, and ethnicity. Journal of Thoracic Oncology. 2009;4(1):37–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19096304

21. Soneji S, Iyer SS, Armstrong K, and Asch DA. Racial disparities in stage-specific colorectal cancer mortality: 1960-2005. American Journal of Public Health. 2010;100(10):1912-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20724684

22. Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJ, and Ezzati M. The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Medicine. 2010;7(3):e1000248. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20351772

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33. Menvielle G, Boshuizen H, Kunst A, Dalton S, Vineis P, Bergmann M, et al. The role of smoking and diet in explaining educational inequalities in lung cancer incidence. Journal of the National Cancer Institute. 2009;101(5):321–30. Available from: http://jnci.oxfordjournals.org/content/101/5/321.long

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Recent references

Eberth, B., D. Olajide, P. Craig, and A. Ludbrook, Smoking-related disease risk, area deprivation and health behaviours. Journal of Public Health, 2013. [Epub ahead of print]. Available from: http://jpubhealth.oxfordjournals.org/content/early/2013/04/02/pubmed.fdt031.long

Singhal, S., C. Quinonez, and P. Jha, An observational study to assess changes in social inequality in smoking-attributable upper aero digestive tract cancer mortality among Canadian males between 1986 and 2001. BMC Public Health, 2013. 13: p. 328.Available from: http://www.biomedcentral.com/1471-2458/13/328

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