9.7 Explanations of socio-economic disparities in smoking

'The relation between SES and smoking patterns is complex involving cumulative and multiple effects across the human life course, possibly extending from one generation to the next.' Gilman et al 20031 p807

Higher smoking rates among disadvantaged groups are associated with a web of interacting physiological, psychological, social, commercial, economic and cultural factors,2 including:

  • nicotine exposure during and before childhood3-6
  • anxiety and depression7-10
  • differences in time preferences11-14
  • parental and peer example15-18,18-21
  • social modelling22-25
  • targeted and more intensive marketing26-29
  • a lower likelihood of working indoors30-32
  • representations of smoking in popular culture.33-36

No doubt different factors are more or less important in explaining socio-economic disparities at different developmental stages37 and at different stages in the tobacco addiction cycle.1, 37 As with other aspects of social disadvantage, many factors driving tobacco-related disparities originate in childhood38-43 and accumulate throughout the individual's life-course.1, 40, 44, 45

While a wealth of information is available and increasingly being collected on associations between various forms of social disadvantage and various aspects of tobacco use,46-48 understanding the causal mechanisms underlying these associations remains elusive.49

One major strand of social epidemiology has used statistical analysis to try to tease out which factors most accurately predict relative rates and relative changes between groups.

An analysis of data from the 1995 Australian National Health Survey, for instance, used multiple logistic regression to examine the association of smoking status with various individual and geographic measures of disadvantage. Analyses showed that gender, age, marital status, country of birth and socio-economic position were all significantly related to smoking status. The odds of being a smoker were largest for respondents who were aged 20–34 years, were not married, had a low socio-economic standing, and were born in the Middle East, southern and western Europe for men, and the UK/Ireland and western Europe for women. The area measure of socio-economic status had a stronger association with smoking likelihood than the individual level indicators (education and income), suggesting a crucial role for the smoker's social environment.50

The Christchurch Health and Development Study, a longitudinal study of the health, development and adjustment of a cohort of New Zealand children born in mid-1977, has concluded that higher rates of cigarette smoking among young adults from socio-economically disadvantaged backgrounds arose from an accumulation of conditions that were more common in children from disadvantaged compared with those from advantaged backgrounds. The researchers concluded that mediating factors that increased the likelihood of uptake of smoking included: lower (conventionally) measured intelligence and poorer school achievement (which they estimated in combination accounted for 56% of the relationship between childhood social disadvantage and later smoking); higher rates of adolescent conduct problems (11%); and greater exposure to parental and peer smoking (26%). These conclusions did not depend on the choice of socio-economic indicators or the age at which smoking was assessed.51

Some researchers assert that it is important to tease out precise differences among different social and cultural groups at various stages in the addiction and lifecycle trajectories.37 Other commentators question the social value of more replication or demonstration of inequalities, and call for a much greater focus in research on the 'black box' of how to go about reducing them.49, 52-54

Beyond social epidemiology, researchers from many other academic and professional disciplines have also explored physiological, psychological and sociological factors related to social disparities in tobacco use. Figures 9.7.1 and 9.7.2 attempt to sketch out how a variety of physiological, psychological and sociological factors may be working to maintain socio-economic disparities in smoking uptake and smoking cessation.


Figure 9.7.1

Figure 9.7.1
Factors driving socio-economic disparities in smoking uptake


Figure 9.7.2

Figure 9.7.2
Factors driving socio-economic disparities in smoking cessation

Source: Thank you to Dr Ron Borland for helping to simplify a previous version of these two diagrams.

Recent news and research

For recent news items and research on this topic, click here (Last updated October 2016)      


1. Gilman SE, Abrams DB, and Buka SL. Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation. Journal of Epidemiolgy and Community Health. 2003;57(10):802-8. Available from: http://jech.bmj.com/cgi/content/abstract/57/10/802

2. Siahpush M. Why is lone motherhood so strongly associated with smoking in Australia? Australian and New Zealand Journal of Public Health. 2004;28(1):37–42. Available from: http://www3.interscience.wiley.com/journal/118803451/abstract

3. Macleod J, Hickman M, Bowen E, Alati R, Tilling K, and Smith G. Parental drug use, early adversities, later childhood problems and children's use of tobacco and alcohol at age 10: birth cohort study. Addiction. 2008;103(10):1731–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18705686

4. Graham H, Hawkins S, and Law C. Lifecourse influences on women's smoking before, during and after pregnancy. Social Science & Medicine. 2009;70(4):582–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19932931

5. Hanson M, and Chen E. Socioeconomic status and health behaviors in adolescence: a review of the literature. Journal of Behavioral Medicine. 2007;30(3):263–85. Available from: https://commerce.metapress.com/content/d15x7n4qj34x5621/resource-secured/?target=fulltext.html&sid=yiupcm55chpbrhe2dzttwwv0&sh=www.springerlink.com

6. Hayatbakhsh M, Mamun A, Najman J, O'Callaghan M, Bor W, and Alati R. Early childhood predictors of early substance use and substance use disorders: prospective study. Australian and New Zealand Journal of Psychiatry. 2008;42(8):720–31. Available from: http://www.informaworld.com/smpp/content~db=all?content=10.1080/00048670802206346

7. Strong D, Cameron A, Feuer S, Cohn A, Abrantes A, and Brown R. Single versus recurrent depression history: differentiating risk factors among current US smokers. Drug and Alcohol Dependence. 2010;109(1-3):90-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20074868

8. Trosclair A, and Dube S. Smoking among adults reporting lifetime depression, anxiety, anxiety with depression, and major depressive episode, United States, 2005-2006. Addictive Behaviors. 2009;35(5):438–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20079577

9. Khaled SM, Bulloch A, Exner DV, and Patten SB. Cigarette smoking, stages of change, and major depression in the Canadian population. Canadian Journal of Pyschiatry. 2009;54(3):204–8. Available from: publications.cpa-apc.org/media.php?mid=759&xwm=true

10. Cougle J, Zvolensky M, Fitch K, and Sachs-Ericsson N. The role of comorbidity in explaining the associations between anxiety disorders and smoking. Nicotine & Tobacco Research. 2010;12(4):355–64. Available from: http://ntr.oxfordjournals.org/content/12/4/355.long

11. Khwaja A, Silverman D, and Sloan F. Time preference, time discounting, and smoking decisions. Journal of Health Economics. 2007;26(5):927–49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17574694

12. VanderVeen JW, Cohen LM, Cukrowicz KC, and Trotter DR. The role of impulsivity on smoking maintenance. Nicotine & Tobacco Research. 2008;10(8):1397–404. Available from: http://www.informaworld.com/smpp/content~content=a901416033~db=all~order=page

13. Businelle M, McVay M, Kendzor D, and Copeland A. A comparison of delay discounting among smokers, substance abusers, and non-dependent controls. Drug and Alcohol Dependence. 2010;112(3):247-50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20696538

14. Fields S, Leraas K, Collins C, and Reynolds B. Delay discounting as a mediator of the relationship between perceived stress and cigarette smoking status in adolescents. Behavioural Pharmacology. 2009;20(5–6):455–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19730366

15. Richter M, Vereecken C, Boyce W, Maes L, Gabhainn S, and Currie C. Parental occupation, family affluence and adolescent health behaviour in 28 countries. International Journal of Public Health. 2009;54(4):203–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19347249

16. Rainio S, Rimpelä A, Luukkaala T, and Rimpelä M. Evolution of the association between parental and child smoking in Finland between 1977 and 2005. Preventive Medicine. 2008;46(6):565–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18289657

17. Paul SL, Blizzard L, Patton GC, Dwyer T, and Venn A. Parental smoking and smoking experimentation in childhood increase the risk of being a smoker 20 years later: the Childhood Determinants of Adult Health Study. Addiction. 2008;103(5):846-53. Available from: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1360-0443.2008.02196.x

18. Audrain-McGovern J, Rodriguez D, Tercyak KP, Neuner G, and Moss HB. The impact of self-control indices on peer smoking and adolescent smoking progression. Journal of Pediatric Psychology. 2006;31(2):139–51. Available from: http://jpepsy.oxfordjournals.org/cgi/content/abstract/31/2/139

19. Melchior M, Chastang J, Mackinnon D, Galera C, and Fombonne E. The intergenerational transmission of tobacco smoking-The role of parents' long-term smoking trajectories. Drug and Alcohol Dependence. 2009;107(2–3):257–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20004064

20. Brook JS, Morojele NK, Brook DW, Zhang C, and Whiteman M. Personal, interpersonal, and cultural predictors of stages of cigarette smoking among adolescents in Johannesburg, South Africa. Tobacco Control. 2006;15(suppl. 1):i48-53. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_1/i48

21. Fraga S, Sousa S, Ramos E, Dias I, and Barros H. Social representations of smoking behaviour in 13-year-old adolescents. Revista portuguesa de pneumologia. 2011;17(1):27-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21251481

22. Sorenson G, Emmons KM, Stoddard A, Linnan L, and Avrunin J. Do social influences contribute to occupational differences in quitting smoking and attitudes toward quitting? American Journal of Health Promotion. 2002;16(3):135–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11802258

23. Kim MJ, Fleming CB, and Catalano RF. Individual and social influences on progression to daily smoking during adolescence. Pediatrics. 2009;124(3):895–902. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891669/

24. DiNapoli P. Early initiation of tobacco use in adolescent girls: key sociostructural influences. Applied Nursing Research. 2009;22(2):126–32. Available from: http://www.appliednursingresearch.org/article/PIIS089718970700095X/fulltext

25. Cutler D, and Glaeser EL. Social Interactions and Smoking. Faculty Research Working Papers Series, RWP08-018. Cambridge, Massachusetts: Department of Economics & John F. Kennedy School of Government, Harvard University, 2008. Available from: http://ksgnotes1.harvard.edu/Research/wpaper.nsf/rwp/RWP08-018/$File/rwp_08_018_glaeser.pdf

26. John R, Cheney MK, and Azad MR. Point-of-sale marketing of tobacco products: taking advantage of the socially disadvantaged? Journal of Health Care for the Poor and Underserved. 2009;20(2):489–506. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19395844

27. Apollonio DE, and Malone RE. Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill. Tobacco Control. 2005;14(6):409-15. Available from: http://tc.bmjjournals.com/cgi/content/abstract/14/6/409

28. Siahpush M, Jones PR, Singh GK, Timsina LR, and Martin J. The association of tobacco marketing with median income and racial/ethnic characteristics of neighbourhoods in Omaha, Nebraska. Tobacco Control. 2010;19(3):256-8. Available from: http://tobaccocontrol.bmj.com/content/19/3/256.abstract

29. Siahpush M, Jones P, Singh G, Timsina L, and Martin J. Association of availability of tobacco products with socio-economic and racial/ethnic characteristics of neighbourhoods. Public Health. 2010;124(9):525-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20723950

30. 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

31. Smith D, and Leggat P. Tobacco smoking by occupation in Australia: results from the 2004 to 2005 National Health Survey. Journal of Occupational and Environmental Medicine. 2007;49(4):437–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17426527

32. Germain D, McCarthy M, and Durkin S. Smoking bans in Victorian workplaces: reduced disparities in exposure to secondhand smoke, 1998 to 2007. CBRC Research Paper Series No 35. Melbourne, Australia: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2008. Available from: http://www.cancervic.org.au/cbrc-smoking-bans-vic-workplaces.html

33. Martyn CN. Smoking in British popular culture 1800-2000. British Medical Journal. 2000;321(7257):389. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10926605

34. Krupka LR, Vener AM, and Richmond G. Tobacco advertising in gender-oriented popular magazines. Journal of drug education. 1990;20(1):15-29. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2348303

35. Healton CG, Watson-Stryker ES, Allen JA, Vallone DM, Messeri PA, Graham PR, et al. Televised movie trailers: undermining restrictions on advertising tobacco to youth. Archives of Pediatrics & Adolescent Medicine. 2006;160(9):885-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16953010

36. Soulos G, and Sanders S. Promoting tobacco to the young in the age of advertising bans. N S W Public Health Bulletin. 2004;15(5-6):104-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15543244

37. Moolchan ET, Fagan P, Fernander A, Velicer W, Hayward MD, King G, et al. Addressing tobacco-related health disparities. Addiction. 2007;102 (suppl. 2):30–42. Available from: http://cat.inist.fr/?aModele=afficheN&cpsidt=19108854

38. Brunner E, Shipley M, Blane D, and al e. When does cardiovasular risk start? Past and present socioeconomic circumstances and risk factors in adulthood. Journal of Epidemiology and Community Health. 1999;53(12):757–64. Available from: http://jech.bmj.com/cgi/reprint/53/12/757

39. Power C, Graham H, Due P, Hallqvist J, Joung I, Kuh D, et al. The contribution of childhood and adult socioeconomic position to adult obesity and smoking behaviour an international comparison. International Journal of Epidemiology. 2005;34(2):344–55. Available from: http://ije.oxfordjournals.org/cgi/content/full/34/2/335

40. Galobardes B, Lynch J, and Smith DG. Childhood socioeconomic circumstances and cause-specific mortality in adulthood: systematic review and interpretation. Epidemiologic Reviews. 2004;26(1):7–21. Available from: http://epirev.oxfordjournals.org/cgi/content/full/26/1/7

41. Harville E, Boynton-Jarrett R, Power C, and Hypponen E. Childhood hardship, maternal smoking, and birth outcomes: a prospective cohort study. Archives of Pediatrics & Adolescent Medicine. 2010;164(6):533–9. Available from: http://archpedi.ama-assn.org/cgi/content/full/164/6/533

42. Evans G, and Kutcher R. Loosening the link between childhood poverty and adolescent smoking and obesity: the protective effects of social capital. Psychological Science. 2010;22(1):3-7. Available from: http://pss.sagepub.com/content/22/1/3.long

43. Topitzes J, Mersky JP, and Reynolds AJ. Child maltreatment and adult cigarette smoking: a long-term developmental model. Journal of Pediatric Psychology. 2010;35(5):484-98. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19995869

44. Case A, Lubotsky D, and Paxson C. Economic status and health in childhood: the origins of the gradient. The American Economic Review. 2002;92(5):1308–34. Available from: http://www.ingentaconnect.com/content/aea/aer/2002/00000092/00000005/art00003

45. Chen E, Martin AD, and Matthews KA. Socioeconomic status and health: do gradients differ within childhood and adolescence? Social Science & Medicine 2006;62(9):2161–70. Available from: http://www.sciencedirect.com/science/article/pii/S0277953605004727

46. Fagan P, Moolchan E, Lawrence D, Fernander A, and Ponder P. Identifying health disparities across the tobacco continuum. Addiction. 2007;102(suppl. 2):5–29. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17850611

47. Harwood G, Salsberry P, Ferketich A, and Wewers M. Cigarette smoking, socioeconomic status, and psychosocial factors: examining a conceptual framework. Public Health Nursing. 2007;24(4):361–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17553026

48. Giordano G, and Lindstrom M. The impact of social capital on changes in smoking behaviour: a longitudinal cohort study. European Journal of Public Health. 2011;21(3):347-54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20570962

49. Birch S. Commentary: Social inequalities in health, social epidemiology and social value. International Journal of Epidemiology. 2001;30(2):294–6. Available from: http://ije.oxfordjournals.org/cgi/content/short/30/2/294

50. Siahpush M, and Borland R. Sociodemographic variations in smoking status among Australians aged 18 years and over: multivariate results from the 1995 National Health Survey. Australian and New Zealand Journal of Public Health. 2001;25(2):438–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11688624

51. Fergusson D, Horwood L, Boden J, and Jenkin G. Childhood social disadvantage and smoking in adulthood: results of a 25-year longitudinal study. Addiction. 2007;102(3):475–82. Available from: http://www3.interscience.wiley.com/journal/117967806/abstract

52. Schaap M, and Kunst A. Monitoring of socio-economic inequalities in smoking: learning from the experiences of recent scientific studies. Public Health. 2009;123(3):103–9. Available from: http://www.publichealthjrnl.com/article/PIIS0033350608003077/fulltext

53. Dixon J, and Banwell C. Theory driven research designs for explaining behavioural health risk transitions: the case of smoking. Social Science & Medicine. 2009;68(12):2206–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19394742

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Recent references

Mental illness

Lawrence, D., J. Hafekost, P. Hull, F. Mitrou, and S. Zubrick, Smoking, mental illness and socioeconomic disadvantage: analysis of the Australian National Survey of Mental Health and Wellbeing. BMC Public Health, 2013. 13: p. 462. Available from: http://www.biomedcentral.com/1471-2458/13/462

Health literacy

Stewart, D., C. Adams, M. Cano, V. Correa-Fernandez, Y. Li, et al., Associations between health literacy and established predictors of smoking cessation. American Journal of Public Health, 2013. [Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23678912

Greater access to products

Wood, L., G. Pereira, N. Middleton, and S. Foster, Socioeconomic area disparities in tobacco retail outlet density: a Western Australian analysis. The Medical Journal of Australia, 2013. 198(9): p. 489-91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23682892

Other factors

Dorner, T., W. Stronegger, K. Hoffmann, K. Stein, and T. Niederkrotenthaler, Socio-economic determinants of health behaviours across age groups: results of a cross-sectional survey. Wiener Klinische Wochenschrift, 2013. [Epub ahead of print]. Available from: http://link.springer.com/article/10.1007%2Fs00508-013-0360-0

Green, M., A. Leyland, H. Sweeting, and M. Benzeval, Socioeconomic position and adolescent trajectories in smoking, drinking, and psychiatric distress. The Journal of Adolescent Health, 2013. [Epub ahead of print]. Available from: http://www.jahonline.org/article/S1054-139X%2813%2900146-8/fulltext


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