Socio-economic disparities are evident in tobacco exposure and use; there is a consistent inverse dose–response relationship between cigarette smoking and income level (i.e., the lower the income the greater the smoking), worldwide and across subgroups.1 Such disparities begin before birth, with higher likelihood of pregnant women from low socioeconomic status backgrounds smoking and being exposed to secondhand smoke, and continue through childhood, adolescence, and adulthood.
This section discusses current disparities in smoking prevalence by socioeconomic status, and section 9.2 provides a detailed overview of these disparities over time.
9.1.1 Disparities in smoking prevalence among adults
Consistent with findings from the US,2 UK,3 Canada,4 New Zealand5 and other developed and developing countries,1 data from recent Australian surveys6, 7 show a clear social gradient in smoking behaviour among adults, with rates of smoking significantly higher in lower socio-economic groups.
Figures 9.1.1 and 9.1.2 set out Australian data from the 2014–15 National Health Survey published by the Australian Bureau of Statistics.7
Figure 9.1.2 shows smoking status by level of social disadvantage. The proportion of ex-smokers is almost identical among people living in the least and most disadvantaged areas; differences in smoking prevalence appear to be largely attributable to fewer socially advantaged people taking up smoking in the first place.
The 2016 National Drug Strategy Household Survey tells a similar story. The disparities between the least and most disadvantaged are much greater among never and current smokers than among ex-smokers. Table 9.1.1 shows smoking status among those of varying levels of social disadvantage, employment status, and education level.
9.1.2 Disparities in reported cigarette consumption
In addition to being more likely to have ever smoked and to be current smokers, those in disadvantaged groups also generally report smoking a greater number of cigarettes each day.8-10 Table 9.1.2 shows the average number of cigarettes smoked per day among adult smokers by social characteristics in Australia in 2016.
9.1.3 Disparities
in duration of smoking
Among people who have quit smoking, those with lower levels of occupation, income and education are likely to have smoked for longer periods of time prior to quitting. Table 9.1.3 sets out the mean number of years spent smoking prior to quitting for people who reported being ex-smokers in the 2001 National Drug Strategy Household Survey.11, 12
Source: Siahpush et al 200512
Note, however that trends in smoking cessation are not uniformly more favourable in higher SES groups for all age and gender groups. In 2016, middle aged (40–59 years) and younger (18–39 years) women with a university education were significantly less likely to have ever smoked than those with lower education levels; however there were no differences among older women (60+ years).13 International research has shown similar patterns.14 These differences in patterns of uptake between cohorts may be explained by trends towards greater social freedom for women since the late 1960s.
In the US, there also appear to be marked differences in the duration of smoking between racial and socio-economic groups. One study found that most minority racial groups were likely to smoke for longer periods and individuals living in poverty smoked on a daily basis for 18 years longer than those with a family income about three times above the poverty line.15
Cohort patterns in smoking uptake and quitting are discussed further in Section 9.7
9.1.4 Disparities in smoking during pregnancy
Disadvantage across a woman’s life course increases her risk of being a smoker during pregnancy.16 Women without a partner, the less educated,17, 18 those of lower socio-economic status,17, 19 those living in a deprived neighbourhood20 and women with a psychiatric disorder21 are more likely to smoke during pregnancy. In 2015, women who were most disadvantaged were about six times more likely to smoke in the first 20 weeks of their pregnancy than women who were least disadvantaged (18% compared to 3%). Those living in very remote areas were also more than four times more likely to smoke than women in major cities (37% compared to 8%). Women with Aboriginal or Torres Strait Islander backgrounds were almost four times more likely to smoke during the first 20 weeks of pregnancy than non-Indigenous women (44% compared with 12%). The likelihood of smoking during pregnancy decreased with maternal age. Thirty-five per cent of women and girls who became pregnant before the age of 20 smoked during the first half of pregnancy.22 Disadvantaged women may also be more likely to take up smoking during pregnancy or in the early postpartum period,23 and are less likely to quit and more likely to start smoking in their second pregnancy.24
9.1.5 Disparities in smoking behaviours among young people
In 2014, among secondary school students aged 12–15, there were no differences in smoking prevalence across different levels of socioeconomic status. Among 16–17 year olds, the most disadvantaged students (those in the 5th quintile) were significantly more likely to be weekly smokers than mid-SES (those in the 3rd quintile), but no more likely to be smokers than the other groups (the second most disadvantaged or the more advantaged students). Figure 9.1.1 shows these proportions by age group.
9.1.6 Disparities in exposure to secondhand smoke
People in more disadvantaged groups are more likely to be exposed to secondhand smoke both in their homes and workplaces.
9.1.6.1 Disparities in children’s exposure to secondhand smoke
Children from disadvantaged families are far more likely to be exposed to secondhand smoke at home. Lower household income, lower parental education level, and living with multiple adult smokers are predictive of children’s exposure to smoking in the home.26, 27
Data from the National Drug Strategy Household Survey show that in 2016, about 28% of households with at least one child under 15 reported having a household member that smokes at least once per day (see Table 9.1.4). Within these households with children, 17% in the most disadvantaged areas reported that the smoker smokes inside the home, compared with 10% within the most advantaged. Given the higher rates of smoking among those in the disadvantaged groups, this means that children from the most disadvantaged areas of Australia were almost four times more likely to be potentially exposed to smoking in their own homes as children from the most advantaged areas. About 7% of these highly disadvantaged children live in a household where someone smokes indoors at least once a day.
* Based on socio-economic indexes for areas, Australian Bureau of Statistics
Although some children of low socio-economic status (SES) smokers are exposed to tobacco smoke in the home, legislative developments, such as Australia-wide bans on smoking in cars carrying children (see Chapter 15, Section 15.7.2.3), and bans in some states/territories on smoking in close proximity to schools and playgrounds, help reduce the number of areas where children may be exposed to secondhand smoke. Widespread smokefree legislation means that children of non-smoking parents might only very rarely be exposed to environmental tobacco smoke.
International research shows the same associations between deprivation and the likelihood of secondhand smoke exposure among children, with parental smoking habits, household poverty, and lower parental educational levels being common predictors of exposure.26-29
9.1.6.2 Disparities in workplace exposure
Since the mid-1980s in Australia, when smoking was banned in the federal public service offices and then, increasingly in big and then smaller companies (see Chapter 15, Section 15.4), people in higher status occupations have been more likely to work in places with total bans on smoking. While most workplaces since the late 1980s have restricted smoking to at least some degree, research in the late 1990s found that blue collar workers were three times more likely to work in environments with no restrictions on smoking (see Figure 9.1.4).
Source: Adhikari and Summerill 199830
With legislation mandating smokefree policies in hospitality venues and in enclosed workplaces in all Australian jurisdictions (with some exemptions, such as high-roller rooms), disparities in workplace exposure to environmental tobacco smoke are no doubt much less pronounced in more recent times. Data collected from annual population surveys in Victoria showed for instance, that the proportion of indoor workers reporting total smoking restrictions at their usual area of work increased significantly between 1998 and 2007, from 91% to 95%. The data indicated there was a relatively uniform increase in workplace smoking bans across all socio-economic groups for this period. However, there was still some disparity between smokefree workplaces, with 91% of warehouse, workshop, and factory workers reporting a smokefree workplace compared to the average of 95% of all indoor workplaces.31
9.1.6.3 Disparities in domestic exposure
In the 2016 National Drug Strategy Household Survey, among households with a smoker, about one in five (20%) reported that the smoker smoked daily inside the home. Looking at education level, 18% of people with a tertiary-level educationreported that the smoker smoked inside, compared with about one quarter (23%) of those who had only completed up to year 11 or less. Similarly, 24% of households with a smoker in the most disadvantaged areas reported daily smoking in the home, compared with 14% of those in the most advantaged areas (see Figure 9.1.5).
Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2013.6
9.1.6.4 Exposure in institutional settings
People spending time in institutions such as correctional facilities, psychiatric hospitals, and drug treatment centres are among the most disadvantaged groups in Australia. Given the much-higher-than-average rates of smoking among residents and clients of such facilities and services, high levels of smoking among staff,32, 33 and fears about the impact of restricting smoking on attendance, treatment, and behaviour,34 it is only in recent times that such institutions have begun to introduce comprehensive smokefree policies. For example, all states and territories except Western Australia have introduced or are planning to introduce complete smoking bans in prisons, and many inpatient psychiatric settings have implemented smokefree policies. Poor adherence and low levels of support in such settings may, however, limit their effectiveness, resulting in levels of exposure to secondhand smoke among highly disadvantaged clients in such facilities much higher than in the general population.35
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