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)      

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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
http://www.ncbi.nlm.nih.gov/pubmed/23663362

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
http://www.ncbi.nlm.nih.gov/pubmed/23579882

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
http://www.ncbi.nlm.nih.gov/pubmed/23643540

 

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