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

This section draws heavily on sources identified and material that appears in Chapter 1, Sections 1.8 to 1.10.

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

9.6.1 People living in regional and remote areas of Australia

About 31.2% of Australians live outside major citiesi; 68.8% live in major cities, 29% in regional areas and 2.2% in remote or very remote areas.2

People living in rural or remote Australia tend to work in more risky occupations and must travel long distances over country roads. They also are much more likely to smoke, be overweight or obese, to drink alcohol in hazardous quantities and to be physically inactive.3

Life expectancy decreases with increasing remoteness. People living in regional or remote areas of Australia are less likely to report being in 'very good' or 'excellent' health.3 The life expectancy of those living in regional areas is one to two years lower, and in remote areas, life expectancy is up to seven years lower compared with those living in major cities.4

Those living in regional and remote areas may face stressors in the form of drought, flooding, heatwaves, bushfires and outbreaks of plant disease, posing a health and economic burden on these populations. Psychological distress, such as depression, has been known to particularly affect these populations. Those living outside major cities are 1.1 times more likely to report suffering a mental disorder than those living in major cities.3

The 2007–08 ABS National Health Survey data show that those living outside major cities report higher rates of arthritis, asthma, diabetes, and heart, stroke and vascular disease.5 In 2010, smoking rates were 28.9% in remote/very remote areas of Australia, 20.7% in outer regional areas, and 19.9% in inner regional areas. For those living in major cities, the prevalence rate was 16.8%.6

According to Australia's Health 2010, participation rates in screening services, such as bowel, breast and cervical screening, did not necessarily show a gradient across geographical areas. Participation rates in the BreastScreen Australia program were significantly higher in those living in regional areas, outer regional and remote locations compared with those in major cities (the exception was very remote areas, where participation rates were significantly lower). Although participation rates in the National Cervical Cancer Screening Program were similar (about 61%) across major cities, inner regional and outer regional locations, it was significantly lower in remote and very remote locations (54.6% and 59.0% respectively). Participation in the National Bowel Cancer Screening Program also showed varying uptake by geographical areas. Inner regional and outer regional locations showed significantly higher levels of participation than major cities (1.1 and 1.03 times that of major cities respectively), while participation was significantly lower in very remote locations (0.7 times that of major cities).3

Living some distance from major population centres, rural populations often lack access to specialist medical and other health services. Because health professionals are in such short supply in rural and remote areas, it is often difficult to find time for preventive health activities. The National Strategic Framework for Rural and Remote Health sets out goals:

  • to improve access to healthcare
  • to ensure effective and appropriate and sustainable healthcare delivery
  • for an appropriate, skilled and well-supported health workforce
  • for collaborative health service planning and policy development and strong leadership, governance, transparency and accountability.7

As part of heath reforms from 2010, the Australian Government subsidised the cost of nicotine replacement therapy patches. From February 2011, all Australians can access subsidised stop-smoking therapy patches. In addition, the reinvigorated National Tobacco Strategy aims to extend the reach of anti-smoking messages in social marketing campaigns through specific media activity aimed at Australians of low socio-economic status and those living in rural areas.8

9.6.2 People born overseas

At 30 June 2010, data on the estimated resident population of Australia (22.3 million people) report that 27% of the population were born overseas (6.0 million people).9 Although migrants to Australia come from more than 200 different countries, the majority of overseas-born residents hail from the UK.3

Moving countries profoundly changes peoples' lives. For many it provides escape from poverty and violence; it almost always gives people the chance, if not to improve their immediate economic situation, to at least provide a much better future for their children. With this may come great optimism and sense of purpose, and strong bonds with and support from others living nearby from the same cultural background. Immigrant populations generally enjoy better reported health and lower rates of disability and hospitalisation than those reported by people born in Australia.10 Rates of mortality for some diseases are higher in some immigrant groups compared with Australian-born residents, for example, lung cancer in people born in the UK, the Netherlands and Ireland; coronary heart diseases in people born in Poland; and diabetes in those born in Germany, Greece, India, Italy, Lebanon and Poland.3,11

But immigration can also result in quite extreme social and cultural isolation and many people who move to Australia from non-English speaking countries are further disadvantaged by lack of access to information, and limited employment opportunities due to less facility with English and lack of recognition of educational and professional qualifications gained overseas. Even with these countervailing forces, the prevalence of mental health problems is not higher in people born in non-English speaking and other countries outside Australia. The National Survey of Mental Health and Wellbeing showed that persons born overseas were considerably less likely to report ever having a mental disorder (defined as lifetime mental disorder) (28.9 per 100 000) than persons born in Australia (48.7 per 100 000) and other predominantly English-speaking countries (50.2 per 100 000). Among those diagnosed at some point with a mental disorder and suffering symptoms recently (12 months prior to the survey), persons born overseas had much lower prevalence compared with those born in Australia and predominantly English-speaking countriesii.3,12

However, there is evidence to suggest that those who speak a language other than English at home are less likely to participate in health services than persons where English is the predominant language spoken at home. Between 2005 and 2006, 45% of females aged 50–69iii years of age who spoke a language other than English participated in breast cancer screening. In comparison, participation rates of females of the same age bracket whose main language spoken at home was English were 59%. In addition, persons who spoke a language other than English at home were less likely to use a health service for a lifetime mental disorder (26 per 100 000 compared with 48 per 100 000 in predominantly English speakers)iv.3, 12

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

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

However, equally it is also possible that moving to Australia increases the likelihood of quitting in those groups who come from countries with less developed tobacco-control policies. As a demonstration of this effect, a study of Asian immigrants to California in the US (a jurisdiction with a strong history in tobacco control), found that Chinese and Korean immigrants to California had much higher quit ratios than among the populations in their respective homelands. The Chinese immigrants in California quit at roughly seven times the rate of Chinese in China, and Koreans in California three times that of Koreans in Korea. The difference in cessation rates was accounted for by the much higher number of quit attempts made by those living in California as opposed to their counterparts in their homeland, suggesting that time spent in an environment with significantly different social norms towards smoking was a driver for quit attempts.14

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

People from non-English speaking backgrounds are less likely to smoke than those where the major language spoken at home is English.6 Data from the National Drug Strategy Household Survey indicate current smoking prevalence for personsvi who speak a language other than English at home is 11.6%, compared with 18.4% of those whose main language spoken at home is English. There were a high proportion of non-smokers in homes where English was not the main language spoken (80.4%), compared with predominantly English-speaking households (55.5%).

The National Health Survey reports similar findings, where prevalence of smoking was 12.2% among thosevii who predominantly speak a language other than English. People migrating to Australia after 1996 are only slightly less likely to be smokers than those arriving prior to 1996, and are also less likely to smoke than the Australian population as a whole.5

However, it also has to be recognised that people in some cultural and linguistic communities smoke at very high rates indeed. Studies from the 1990s indicated that among the Arab-speaking population in Sydney, more than 50% of both males and females reportedly smoked;15 among the Sydney-based Lebanese community, about 49% of males and 29% of females were smokers16. Male members of the Vietnamese community in Sydney had smoking rates of 53%.17

The '45 and Up Study' in Australia demonstrates how smoking prevalence can vary across cultural sub-groups. It examined smoking characteristics of Australian migrants compared with those of Australian-born residents aged 45 years and older and found that compared with Australian-born men, a higher proportion of men born in Europe, North Africa and the Middle East were current smokers. Compared with Australian-born women, a lower proportion of women from East and Southeast Asia were current smokers and a higher proportion of women from New Zealand and the UK/Ireland were current smokers. Among women born in Asia, the risk of smoking increased significantly the younger they migrated to Australia. The duration smoked and amount smoked per day was primarily lower among migrants than Australian-born persons.18

A study of Arabic-speaking patients seen in the general practice setting in New South Wales found that of more than 1000 patients seen by the general practitioner, 29.7% were smokers. Smokers were also more likely to report poorer overall health and high nicotine dependence. Nicotine dependence was highest in Arabic-speaking males.19

Further studies from New South Wales show that while school children within families from high-smoking communities have a lower prevalence of smoking than their counterparts from English-speaking homes,20 older teenagers are more likely to take up smoking once parental controls reduce.16, 21

While being born overseas in itself is not a risk factor for smoking, being a member of a community where smoking is common may increase health and financial problems of families affected. In Canada, a study of overseas-born children found that the likelihood of smoking increased with the years spent living in Canada, suggesting that the unhealthy behaviours arose after time in their new homeland.22 A similar finding was made in the US, where a survey of Hmong American youths and adults found that among youth, 15% reported daily smoking use and 32% reported ever smoking. The odds of ever use of tobacco increased as the percentage of life lived in the US increased.23

As with other disadvantaged smokers, smoking must also contribute to financial stress. With prices of tobacco products much higher in Australia than in their countries of birth, spending on tobacco products among recent immigrants who smoke must significantly reduce funds available for family goals such as saving for a home, education in a private school and assisting other family members both in Australia and overseas. A US study examined the influence of financial strain on quitting success among a group of smokers from Latino, African American and Caucasian background. They found that greater financial strain at the outset was significantly associated with reduced odds of abstinence at 26 weeks post-quit. They concluded that greater financial strain predicted lower cessation rates among racially/ethnically diverse smokers.24

People from cultural backgrounds where smoking is prevalent may face cultural resistance to quitting due to traditional beliefs and attitudes to smoking.15 Continued smoking by family and friends may make it harder to contemplate quitting and increase chances of relapse in those who give it a go. People from culturally and linguistically diverse (CALD) backgrounds also lack access to information due to language barriers. Providing education and support to Australians with different cultural backgrounds provides particular challenges for public health policy, as has been recognised by the National Tobacco Campaign.8

9.6.3 Lone parents, especially lone mothers

In 2009–10, one in five children aged younger than 17 years (20%) had a natural parent living elsewhere (about one million children). For the majority of these children (81%), this person was their father. Almost three-quarters of children with a parent living elsewhere were in one-parent families.25

Lone mothers and their children are one of the most disadvantaged groups in many countries26 and suffer higher risks of poverty and ill-health than other family types.27,28

Lone parents tend to have higher levels of unemployment, in part due to caring responsibilities, and are more likely to experience financial hardship.29 Rahkonen and colleagues reported the more the economic hardship the more smoking was prevalent among subjects of their study in Finland. The association between economic hardship and lone parenthood was significant independent of other factors such as education, occupational social class, household disposable income, housing tenure or social relations for both men and women.30

In Australia in 2009–10, three in five (59%) of lone parent households with dependent children were classified as having 'low economic resources'.viii One-parent households accounted for 6% of all households, but made up 18% of low economic resource households.25 In the same year, expenditure on tobacco products in single parent households with dependent children was on average $16.83 per week.31 In comparison, coupled households with dependent children spent $11.86 per week.31

Australian research conducted in the early part of the 2000s found that the overall prevalence of smoking among lone mothers was about 46%, with those younger in age (18–29 years) reporting the highest prevalence (59%).32 Lone mothers who were younger, less educated, received government pension/benefits, occupied rental housing, or who lived in more disadvantaged areas were more likely to smoke than others. A strong 'lone mother effect' remained after controlling for socio-economic variables. The odds of smoking for lone mothers were 2.4 times greater than for married mothers (95% CI: 2.0–2.9) and twice as large as those for women living alone (95% CI: 1.6–2.4).33

As highlighted by Hilary Graham in her extensive research and writing about smoking in lone mothers in the UK,27,34-40 smoking status among this group is associated not just with the difficult circumstance they face in the present,41 but also by 'longer term biographies of disadvantage.'34

Lone mothers are much less likely than mothers with partners to quit or suspend smoking during pregnancy. And mothers who continue to smoke during pregnancy are much more likely to report having a difficult, fussy baby, further adding to the stress of looking after children without a partner present.42,43

In 2010, the National Drug Strategy Household Survey reported current smoking prevalence in single-parent households with dependent children was 36.9%. This was over double the current smoking in coupled households with dependent children, where prevalence was 17.9%. Single-person households without children had a current smoking prevalence of 23.8%. Lone households with dependent children also smoked more cigarettes than other households with dependent children, with an average of 110 cigarettes smoked per week, compared with an average of 95.4 cigarettes smoked per week in households headed by a couple.6

Gartner and Hall reported that in Australia between 2001 and 2010 the proportion of households containing a smoker and a child under the age of 15 declined both in lone parent households and households headed by a couple. However the decline was more profound in two-parent households, with about half of lone-parent households with dependent children still smoking in 2010. Lone-parent households with dependent children had a greater percentage increase between 2001 and 2010 in only smoking outdoors while at home, compared with two-parent smoking households. However, lone-parent households were still half as likely to smoke only outdoors as two-parent households.44

Table 9.6.1
Prevalence of smoking in households containing a child under the age of 15 overall and according to household structure, 2001–10






% change between 2001 and 2010



95% CI


95% CI


95% CI


95% CI


95% CI

Smoker(s) in household

































Smoker(s) in smoking households only smoke outdoors

































Source: Gartner and Hall (2012)44

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

Children who live in households with a smoker suffer from more respiratory diseases45 and respiratory illnesses occur more frequently and more severely in those exposed to environmental tobacco smoke.46 Children of lone parents who smoke are also much more likely than children in two-parent families (and than children of lone parents who do not smoke) to begin smoking as teenagers,47–49 thus the effects of smoking are perpetuated across the generations.

9.6.4 People with mental illnesses

Mental health problems are common within the Australian population. Mental disorders are the third leading 'broad cause' of Australia's disease burden, behind cancer and cardiovascular disease.3 The National Survey of Mental Health and Wellbeing indicates one in five Australians between 16 and 85 years have suffered from one or more of the common mental disorders in the 12 months before the survey (categorised by mood disorders, such as depression, anxiety disorders and substance use disorders). Among young people aged 16–24 years, as many as one in four persons reported a mental disorder at some time in the preceding 12 months.3,12

The National Drug Strategy Household Survey reports that smokers were twice as likely as non-smokers to report being diagnosed with, or treated for, a mental illness. Smokers were also more likely to report high or very high levels of psychological stressix in the four-week period before the survey.6 Mental illness and disadvantage

People with serious mental illnesses are very seriously disadvantaged in employment, housing, and just about every sphere of life. They report higher rates of unemployment, are at a greater risk of homelessness, and are more likely to have lower levels of educational attainment than the general population.50

Current tobacco use is strongly associated with a range of other substance use and mental health problems.51,52 In the US and Australia, adults reporting with mental disordersx in the 12 months before the survey smoked at almost double the rate of adults without mental disorders.54 Mental health problems are higher in the other highly disadvantaged groups discussed in this section. Smoking among those with long-term mental health or behavioural problems

Refer to Chapter 7, Section 7.12 for a full discussion on smoking prevalence among those who report mental health problems. Smoking among those with serious psychiatric illnesses

The 2010 National Survey of Psychotic Illness indicates 64 000 Australians aged 18–64 years have a psychotic illness (4.5 cases per 1000 in the 12-month period to March 2010). Psychotic illnesses can include schizophrenia, schizoaffective disorders, bipolar disorder and depression. The most common reported disorder was schizophrenia, accounting for 47% of all psychotic disorders. Schizophrenia accounted for more than half of psychotic disorders among males (56.3%) and one-third of psychotic disorders among females (33.2%).50

The survey indicates smoking rates among Australians with a psychotic illness were 67.2% in 2010, declining only a little since 1997–98, when current smoking prevalence among this population was 68.9%. Sixty-six per cent of people with psychosis reported smoking an average of 21 cigarettes per day. 50

A review of 42 international studies in 20 nations found an average smoking prevalence among people with schizophrenia of 62%.55 Diaz and colleagues reported from their study of smoking prevalence among patients with bipolar disorder, schizophrenia and major depression that daily smoking rates among those with major depression were 57%, and 66% among those with bipolar disorder. Among patients with schizophrenia, daily smoking prevalence was as high as 74%.56

The interaction between tobacco use and mental illness is complex and likely to reflect a number of factors; the complexity of these interactions and associations has been well examined among adults as well as among adolescents and children.52,57-59

Swendson and colleagues set out to examine mental disorders and risk factors for later onset of nicotine, alcohol and drug use, abuse and dependence. Behavioural disorders and pre-existing substance abuse were predictive of later transition to substance abuse. They concluded there was significant prospective risk associated with baseline mental disorders for the onset of nicotine, alcohol and illicit drug dependence with abuse over the study follow-up period (10 years after baseline). However they noted the complexity in these associations, in that the magnitude of associations varied across categories of mental disorders and there were differences observed across mental disorder and the onset of use, abuse and dependence with abuse. For example, their analysis suggested that certain conditions, such as anxiety or additional substance use disorders, play a fairly stronger role in the initial onset of daily smoking or drug use than in the onset of dependence. In comparison, many forms of disorder were more strongly associated with transitions to dependence on alcohol than with the onset of use or abuse of alcohol.60

Smith and colleagues reported patients with a first episode of psychosis actually initiated smoking before the first signs of illness (psychosis), suggesting smoking may not have been a response to the early signs of the illness. They reported subjects were vulnerable to the same predictors of smoking uptake as the general population, particularly prenatal tobacco exposure, which is also known to be connected with other medical, cognitive and behavioural problems.61

People with mental health illnesses who live in institutions have higher rates of smoking than those living in the community.62 For inpatients in an institution, environment may reinforce smoking behaviour.63 Many patients report smoking more due to boredom.64 Smoking may also be seen as a means of reclaiming a degree of self-determination and autonomy in the face of disempowerment.65 Although most patients with a psychiatric condition report that they smoke for the same reasons as other smokers (including 'addiction', for 'relaxation' and to 'calm down')66–68 there is evidence that nicotine may serve for some as a form of self-medication to ameliorate symptoms of certain mental illnesses, or to alleviate side effects of prescribed medication.62,66,67 Financial stress among those with mental illness who smoke

The interaction between poor mental health and poverty and/or financial stress is well known; understanding its mechanism was a subject of study for Jenkins and colleagues. They found that the most disadvantaged, by low income, were more likely to have a mental disorder. Twenty-three per cent of subjects with a mental disorder were in debt, compared to 8% of those without a mental disorder; the more debt the subjects had, the more likely they were to have some form of mental disorder. They concluded that low income and debt were associated with mental illness but the effect of income was mediated largely by debt.69

In Australia in 2000, it was estimated that people with a psychotic illness who smoked and were in receipt of a disability support pension spent more than one-third of their pension on tobacco products, and contributed a total of about $111 million each year in tobacco taxes to the Australian Government. According to this study, smoking contributes to the vicious cycle of poverty and disadvantage in which many mentally ill people are trapped.65

In 2010, the Australian national survey of people living with psychotic illness reported 85% of persons with a psychotic illness obtained their main source of income from government payments. One-third of those with a psychotic illness had been in paid employment in the past year (32.7%) and one in five was employed at the time of the survey interview (21.5%). In comparison, about 72% of the general working age population (age 15–64 years) were employed in July 2010.

One in twenty with a psychotic illness were homeless at the time of interview, one in ten (11.0%) were in supported accommodation, and only 15% had some form of private health insurance.

Smoking status and gambling have also been associated with psychiatric symptoms.70 Smoking prevalence has been reported to be very high among people who call helplines for problem gamblers (over 43% in one US study).71 Preventable diseases among those with mental illness who smoke

The higher rates of smoking among people with mental health problems and mental illnesses means that they are more likely to suffer all the various health problems associated with tobacco use. Those with psychotic illnesses report higher rates of asthma, heart and/or circulatory conditions, arthritis, diabetes, kidney disease and stroke.50

People with mental illness may not be as frequently or intensively counselled about preventive health issues by health practitioners very much focused on managing immediate symptoms of mental illness.72 Studies report, however, that risks of cardiovascular disease can be reduced by interventions to stop smoking among patients with mental illness.73,74

US research has indicated a 20% reduction in life expectancy among people suffering from schizophrenia,75 with heart disease being the most common cause of death.76 Barriers to cessation among those with mental illness

Refer to Chapter 7, Section 7.12.4 for a full discussion on smoking prevalence among those who report mental health problems.

9.6.5 People with alcohol and drug problems

Material in this section draws heavily on a comprehensive review produced by Baker et al published in the Drug and Alcohol Review in 2006.77

People with mental health problems are much more likely to suffer from alcohol and other drug problems,78 including smoking,79 and tobacco use commonly co-exists with other drug use (see Chapter 1, Section 1.10.6). The National Drug Strategy Household Survey reported the diagnoses or treatment for a mental illness was much more common in those who had used illicit drugs in the last 12 months (18.7%), and in the last month (20.4%) compared with those who had not used illicit drugs in the past 12 months (10.8%). Illicit drug users also had higher levels of psychological distress than non-users.6

A US study examined psychiatric co-morbidity associated with nicotine addiction among alcohol-dependent respondents in the general population. Forty-eight per cent of the alcohol-dependent respondents reported nicotine dependence. In addition they reported 'higher lifetime rates of panic disorder, specific and social phobia, generalised anxiety disorder, major depressive episode, manic disorder, suicide attempt, antisocial personality disorder and all addictive disorders than those without nicotine dependence'.80

Most individuals presenting for treatment for substance use disorders smoke tobacco as well.77 Australian research68,79 shows that in this population, smoking rates range from 68% to 90%.68 Among mentally ill inpatients with co-existing alcohol and other drug problems, smoking rates as high as 90% have been observed.68

The relationship between tobacco and other drug use is complex, and may be subject to genetic and neurobiological determinants, as well as psychological and social influences.81–83

As pointed out by Baker and colleagues, those with substance abuse problems who also smoke tobacco

'... are at particularly high risk of experiencing harm as a consequence of a typically heavier pattern of tobacco use ... and due to the synergistic effects of these substances. It has been estimated that the combined health risks of smoking and alcohol use are 50% higher than the sum of their individual risks. For example in the case of oesophageal cancer, the excellent solvent properties of alcohol may take the carcinogen in tobacco smoke to basal layers. In addition, people with severe alcohol and drug dependence problems are more likely to die from tobacco-related causes such as coronary heart disease, cancer, stroke and chronic lung disease, than from caused related to the use of any other drugs.' Baker et al 200677 (p87)

Cessation interventions tailored to the needs of poly-drug users are discussed in Chapter 7, Section 7.12.5.

9.6.6 The homeless

Homelessness is defined as lacking adequate access to safe and secure housing. In 2010, 1.1 million Australian adults (7% of the 16.8 million adult population living in private dwellings) had experienced homelessness at some time in the previous 10 years. They were mostly younger adults (18–34 years) who had lower levels of education, were more likely to have been unemployed in this period, derived their main income from government pensions or allowance and had experienced financial stress compared with those who had not been homeless. They were also more likely to report disability or a long-term health condition. Reports of psychological disability or restriction in the homeless were four-fold compared with those who had never been homeless (22% compared with 5%).25

Individuals experiencing homelessness have a poorer health status than the general population, with the 'street homeless' (those usually dwelling on streets or in parks, in derelict buildings or other temporary shelters) being the worst affected.84 Melbourne-based research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%.84

People who live 'rough' are unlikely to see media advertising about the dangers of smoking. Unrestricted smoking outdoors is likely to result in the development of high levels of dependence on tobacco-delivered nicotine. Research conducted by Apollonio and colleagues suggest that the mentally ill and homeless have been the subject of cigarette promotion and marketing in the past.85

9.6.7 Prison populations

At 30 June 2011, there were 29 106 prisoners (sentenced and unsentenced) in Australian prisons. Of the total prisoner population, 7% (2028) were female and approximately 8 in 10 (79% or 23 082) were born in Australia.86

The prevalence of smoking in the prison population is far higher than among the general population,87,88 and tobacco use is commonly accepted as part of prison life.88 Prison entrants in Australia are more than three times as likely as those in the general population to be daily tobacco smokers (74% compared with 20%).3, 5 It is not unusual for tobacco to be used as currency in gambling or other trade.88

Papododima and colleagues found about 80% of prisoners in their study identified as current smokers, with 43% reporting deterioration of smoking habits when incarcerated. Heavy smoking was linked to past adverse childhood events and personality traits, such as impulsivity, among prisoners.89

Research undertaken in 2001 examining smoking among New South Wales prisoners found that 78% of male and 83% of female inmates were smokers.88 Most (95%) inmates smoked roll-your-own cigarettes, a far higher proportion than that seen in the rest of the population.88 Forty-one per cent of prisoners who smoked reported that they smoked more heavily in prison than when in the community. Illicit drug use was closely connected to tobacco use, with about 90% of individuals who had ever injected drugs, or used cannabis, being smokers as well.88 Eighty-six per cent of inmates aged under 25 were smokers, compared with 64% of prisoners aged over 40. Prisoners who smoked were less likely to have completed their schooling. A small number of smokers had started smoking in prison (7%).88

A 2008 study of prisoners in three metropolitan intake prisons in Adelaide found many prisoners used multiple substances, with the six most common substances used at high and moderate risk levels being tobacco, cannabis, amphetamines, opiates, alcohol and sedatives. Of these, tobacco was the mostly commonly used substance among male and female prisoners.90

The elevated smoking rates in the prison population reflect, to a large extent, increased likelihood of disadvantaged socio-economic backgrounds in inmates.91 Indigenous people make just over a quarter (26% or 7656) of the total prisoner population.86 Drug users and the less educated are over-represented in the prison system, as are those suffering mental disorder.92

Younger prison entrants (age 25–34 years) in Australia were more likely than their counterparts in the general population to have asthma (15% compared with 10%) and diabetes (2% compared with 1%). The high rates of diabetes are likely linked to the large proportion of Indigenous Australian prisoners, where prevalence of diabetes in this group is higher than non-Indigenous Australians. Prisoners aged 35–44 years were also twice as likely to have cardiovascular disease compared with those aged 35–44 years in the general population.3,5,93

The 2007 National Survey of Mental Health and Wellbeing reported incidence of mental disorders among individuals who had at some time been imprisoned was greater than among those who had not (41% compared with 19%).12 Findings from the National Prisoner Health Census showed a similar pattern of mental health problems among prison entrants. A history of mental health problems was more common among female prison entrants and close to a third of prison entrants were referred to prison mental health services as a result of their initial health assessment. More than one-third of the 549 prisoner entrants reported ever being told by a doctor, psychiatrist, psychologist or nurse that they had a mental disorder.3,93

Exposure to secondhand smoke in prisons must be very high, even though smoking has been increasingly restricted in indoor areas.94 Ill-health due to tobacco and spending on tobacco products must create significant challenges for prisoners trying to secure a job and a safe and secure place to live once they are released from prison. Both these factors reduce the chances of reoffending and are crucial for the successful transition to life outside prison. Thibodeau and colleagues reported smoking intention prior to release from prison was predictive of smoking behaviour post-release. Belief in improved health after release was associated with non-smoking at release from prison.95

Prisoners are part of the key target group in the Australian Government's National Tobacco Campaign, where a $27.8 million anti-smoking social marketing campaign is being implemented to target tobacco use in high-risk and high-need groups.8,96

9.6.8 Veterans

Tobacco use has historically been a part of defence force culture, with tobacco being provided and promoted to troops in the past.97– 100 Stress and trauma associated with war deployment has been associated with the uptake of smoking, resumption of smoking and overall high rates of smoking compared with the general population.101,102 More recently, research has been conducted to determine how to effectively denormalise smoking in the military and reduce barriers to smoking cessation.103

In 2006, the 'Your Lives, Your Needs' survey was conducted to assess the health and wellbeing of Australia's Department of Veterans' Affairs veteran community. It surveyed two groups: Veterans' Entitlements Act 1986 clients (80% were aged 65 years plus) and Safety, Rehabilitation and Compensation Act 1988 clients (almost 60% were aged under 45). The older clients (65 years plus) were less likely to rate their health as very good or excellent compared with general community aged 65 years of age plus (21% compared with 36%). Among the younger clients, the difference was much more marked, with only 10% of veterans reporting their health as very good or excellent, compared with over 60% in general population aged 45 years and under. In 2009, 50 000 Department of Veterans' Affairs clients had accepted one or more mental health disability claims associated with their participation in war or defence service. The most common reported conditions were post-traumatic stress disorder, anxiety, substance abuse and depression.3

While military personnel have one of the highest rates of smoking among adults in the US,104–106 a more recent qualitative study of US defence personnel found that the primary strength of its tobacco-control program was the provision of stop-smoking services among its military installations, which include counselling and access to pharmacotherapy. Opinions were mixed on tobacco-control strategies for the military, with some response favouring a tobacco-free environment, while others were concerned about the unintended consequences of a complete ban on tobacco in the service.107 Studies of US war veterans conclude that additional effort is required to support smoking cessation in this community of particularly high smoking prevalence.105,106,108

A study of returned servicemen from the Iraq war and the Afghanistan war indicated an association between heavy daily smoking and emotional numbing, suggesting that veterans suffering post-traumatic stress, smoke to overcome trauma.109

Less information is available about current smoking rates among either active service personnel or veterans in Australia. Based on the relative incidence of smoking-related cancers, smoking rates among veterans of the Korean war are believed to be higher than those of the general population.110 Smoking may interact with exposure to other carcinogenic agents during war service, resulting in higher cancer rates in this group. A study of Australian Army Vietnam veterans aimed to assess the relationship between military and war service with mortality and length of life, 36 years after repatriation from the Vietnam War. Their findings indicated that mortality risks among these veterans are linked to regular enlistment, an increased chance of not being in an intimate relationship later in life and increased risk-taking behaviour either during service or higher rates of health-risk behaviours, such as smoking, post-service. They concluded that increased risk of mortality among these veterans is likely to arise from health-risk behaviour such as smoking, inactivity and poor diet, rather than from war service per se or psychiatric disorder.111

9.6.9 Indigenous communities

Refer to Chapter 8 for a full discussion on smoking in Australia's Indigenous communities.

9.6.10 Vulnerable youth

While generally they enjoy very good health, there are rising rates of obesity and sexually transmissible infections as well as higher levels of physical inactivity in young Australians aged 15–24 years. Many are using an illicit drug, consuming alcohol at harmful levels and are burdened by mental disorders.3 Prevalence of tobacco smoking in Australians aged 15–24 years was estimated to be 17% in 2007.3,5

Prevalence of asthma among Australian males and females aged 15–24 years was about 11% in 2007–08. It was just under 12% in males aged 10–14 years and about 7% in females of the same age.112 Asthma attacks are more common and more severe in young people exposed to secondhand smoke.113 Disadvantaged parents are much more likely to smoke indoors than more advantaged parents.44, 114-116 Asthma symptoms are more poorly managed and more frequent in children who live in families in more disadvantaged neighbourhoods.117

Indigenous children and children of non-Indigenous lone mothers, people suffering mental disorders, people with substance abuse problems and prisoners must all be at particular risk of harm caused by tobacco use in addition to exposure to secondhand smoke. Spending on tobacco products in low-income families can mean reduced expenditure on recreational activities, education and even food for children in very disadvantaged families.118 Such children are much more likely to lose a parent (and breadwinner) due to illness and premature death caused by smoking. Absence of smoking restrictions at home is associated with increased risk of smoking uptake by children.119,120 Smoking by parents is highly associated with the uptake of smoking and other high-risk behaviours in children.121

Young people from disadvantaged families who are already facing difficult personal circumstances are at particularly high risk of taking up smoking. Concurrent use of alcohol and tobacco use during early adolescence has been found to be associated with risk factors that are predictive of alcohol use and dependence later in life.122 Furthermore, disadvantaged youth exposed to more substance users in their social groups report greater alcohol, cigarette and marijuana consumption regardless of whether members of the social group provided tangible or emotional support.123

Mental health problems in young people are strongly associated with engagement in risky behaviours.124 Smoking rates are high among young people in institutional care125 and screening and treatment for smoking is often not addressed in institutional care.126 Depression vulnerability was found to be predictive of smoking among young female college students in the US.127 Among boys admitted to psychiatric inpatient care in Finland, cannabis and hard drug use was associated with past placement in child welfare.83

One international study suggests that smoking by adolescents may limit their subsequent life chances independent of the effects of socio-economic status.128 Anecdotal evidence suggests that smoking status in Australia may be starting to affect employability and to limit choices in housing and in dating129 and, therefore, perhaps also in the establishment of long-term relationships.

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i As classified by the Australian Standard Geographical Classification (ASGC)1

ii Unpublished Australian Institute of Health and Welfare analysis from the Australian Bureau of Statistics 2007 National Survey of Mental Health and Wellbeing. Reported in Australia's Health 20103. 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 (p271)

iii 50–59 years of age is the target age bracket for breast cancer screening.

iv Unpublished Australian Institute of Health and Welfare analysis from the Australian Bureau of Statistics 2007 National Survey of Mental Health and Wellbeing. Reported in Australia's Health 20103. 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 (p273)

v Researchers, however, have demonstrated an inverse social gradient among women of Turkish and Moroccan background who have immigrated to The Netherlands.13. Nierkens V, de Vries H, and Stronks K. Smoking in immigrants: do socioeconomic gradients follow the pattern expected from the tobacco epidemic? Tobacco Control. 2006;15(5):385–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16998173

vi Persons aged 14 years plus

vii Persons aged 15 years plus

viii Where the average weekly equivalised adjusted disposable household income was $465. For a full explanation see Australian Bureau of Statistics, 4102.0 Australian Social Trends, March quarter 2012.25. 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

ix Refers to level of anxiety and depressive symptoms a person may have felt in the preceding four-week period.25 Ibid.

x As classified by the International Classification of Diseases, 10th edition (ICD-10).53. World Health Organization. International Classification of Diseases (ICD). Geneva: WHO, 2012. [viewed 5 May 2012] . Available from: http://www.who.int/classifications/icd/en/


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Recent references

OS born

Li, S., S. Kwon, I. Weerasinghe, M. Rey, and C. Trinh-Shevrin, Smoking among Asian Americans: acculturation and gender in the context of tobacco control policies in New York city. Health Promotion Practice, 2013. [Epub ahead of print]. Available from: http://hpp.sagepub.com/content/early/2013/05/09/1524839913485757.long

Mental illness

Heffner, J., R. Anthenelli, C. Adler, S. Strakowski, J. Beavers, et al., Prevalence and correlates of heavy smoking and nicotine dependence in adolescents with bipolar and cannabis use disorders. Psychiatry Research, 2013. [Epub ahad of print]. Available from: http://www.psy-journal.com/article/S0165-1781%2813%2900198-4/fulltext

Single parent females

Chapman, S. and L. Wu, Substance use among adolescent mothers: a review. Children and Youth Services Review, 2013. 35(5): p. 806-15.Available from: http://www.ncbi.nlm.nih.gov/pubmed/23641120

Drug users

Nehlin, C., L. Gronbladh, A. Fredriksson, and L. Jansson, Alcohol and drug use, smoking, and gambling among psychiatric outpatients: a 1-year prevalence study. Substance Abuse, 2013. 34(2): p. 162-8 Available from: http://www.tandfonline.com/doi/full/10.1080/08897077.2012.728991#.UYYynErYGSo http://www.ncbi.nlm.nih.gov/pubmed/23577911

Goldberg, S., K. Strutz, A. Herring, and C. Halpern, Risk of substance abuse and dependence among young adult sexual minority groups using a multidimensional measure of sexual orientation. Public Health Reports, 2013. 128(3): p. 144-52.Available from: http://www.ncbi.nlm.nih.gov/pubmed/23633729


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