9.1 Socio-economic position and disparities in tobacco exposure and use

Last updated: October 2019

Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.1 Socio-economic position and disparities in tobacco exposure and use. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2019. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-1-socioeconomic-position-and-disparities-in-toba

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 Zealand 5  and other developed and developing countries, 1  data from recent Australian surveys 6, 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 9.1.1 
Prevalence of daily smoking, Australians 15 years and over by socio-economic and labour force status, 2014‒15

Source: Australian Bureau of Statistics 2016 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. 

Figure 9.1.2 
Smoking status by quintile of relative social disadvantage, persons 18 years and older, Australia, 2014–15

Source: Australian Bureau of Statistics 2016 7

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. 

Table 9.1.1 
Socio-economic characteristics by smoking status, persons 18 years and older, Australia, 2013

Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2016. 6

* Never smoked more than 100 cigarettes or the equivalent tobacco in their life 
† Smoked at least 100 cigarettes or the equivalent tobacco in their life, and no longer smoke 
‡ Smoked daily, weekly or less than weekly

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. 

Table 9.1.2 
Mean number of cigarettes smoked per day, (self-reported) current smokers aged 18 years and older, by social characteristics, by sex, Australia, 2016

Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2016. 6

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

Table 9.1.3 
Mean duration of smoking prior to quitting, Australia, 2001

Source: Siahpush et al 2005 12

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 neighbourhood 20   and women with a psychiatric disorder 21  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 2017, among Australian students aged 12–15, those living in areas with relatively greater socioeconomic disadvantage (first quintile) were significantly more likely to report current smoking (in the past week) than those who lived in relatively less disadvantaged areas (fifth quintile). Among 16–17 year olds, current smoking did not vary significantly with socioeconomic status. 25  Figure 9.1.3 shows these proportions by age group.

Figure 9.1.3 Proportion reporting smoking a least weekly, secondary-school students aged 12–15 and 16–17 years by Index of Socio-economic Disadvantage of place of residence, Australia, 2017

Source:  Bain, E., Guerin, N., & White, V. 2019. 25

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.  

Table 9.1.4 
Percentage of households with children under 15 years that allow indoor smoking, by quintile of disadvantage*, Australia, 2013

Source: Centre for Behavioural Research in Cancer analysis of National Drug Strategy Household Survey data 2013. 6

* 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). 

Figure 9.1.4 
Proportion of workers reporting a total ban and proportion reporting no restrictions on smoking in their workplace, Australia 1998: blue collar compared to white collar and professional workers

Source: Adhikari and Summerill 1998 30

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). 

Figure 9.1.5 
Proportion of households with a smoker that allow smoking indoors by SEIFA and education level, Australia, 2013

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   

Relevant news and research

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References

1. Casetta B, Videla AJ, Bardach A, Morello P, Soto N, et al. Association between cigarette smoking prevalence and income level: A systematic review and meta-analysis. Nicotine & Tobacco Research, 2017; 19(12):1401–7. Available from:  http://ntr.oxfordjournals.org/content/early/2016/09/27/ntr.ntw266.abstract

2. Centers for Disease Control and Prevention. Burden of tobacco use in the US. 2017. Available from:  https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html

3. NHS Digital. Statistics on smoking, England - 2017. 2017. Available from:  http://digital.nhs.uk/catalogue/PUB24228

4. Statistics Canada. Smoking, 2016. 2017. Available from:  https://www.statcan.gc.ca/pub/82-625-x/2017001/article/54864-eng.htm

5. Ministry of Health. Annual update of key results 2016/17: New Zealand Health Survey. 2017. Available from:  https://www.health.govt.nz/publication/annual-update-key-results-2016-17-new-zealand-health-survey

6. Australian Institute for Health and Welfare, National Drug Strategy Household Survey, 2016 [computer file]. Canberra: Australian Data Archive, The Australian National University; 2017.

7. Australian Bureau of Statistics. 4364.0.55.001 National Health Survey: First results, 2014–15  2016. Available from:  http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4364.0.55.001Main+Features100012014-15?OpenDocument

8. 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://www3.interscience.wiley.com/journal/118996678/abstract

9. Siahpush M. Smoking and social inequality. Australian and New Zealand Journal of Public Health, 2004; 28(3):297. Available from:  http://www3.interscience.wiley.com/journal/118803503/abstract

10. Pennanen M, Broms U, Korhonen T, Haukkala A, Partonen T, et al. Smoking, nicotine dependence and nicotine intake by socio-economic status and marital status. Addictive Behaviors, 2014; 39(7):1145–51. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/24727110

11. Australian Institute of Health and Welfare. 2001 National Drug Strategy Household Survey: Detailed findings. Drug statistics series no. 11, AIHW cat. no. PHE 41.Canberra: AIHW, 2002. Available from:  https://www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/2001-ndshs-detailed-findings/contents/table-of-contents 

12. Siahpush M, Heller G, and Singh G. Lower levels of occupation, income and education are strongly associated with a longer smoking duration: Multivariate results from the 2001 Australian national drug strategy survey. Public Health, 2005; 119(12):1105–10. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/16085150

13. Australian Institute of Health and Welfare. National Drug Strategy Household Survey, 2013 [computer file], 2015, Australian Data Archive, The Australian National University: Canberra.

14. Bricard D, Jusot F, Beck F, Khlat M, and Legleye S. Educational inequalities in smoking over the life cycle: An analysis by cohort and gender. International Journal of Public Health, 2016; 61(1):101–9. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/26310848

15. Siahpush M, Singh G, Jones P, and Timsina L. Racial/ethnic and socioeconomic variations in duration of smoking: Results from 2003, 2006 and 2007 tobacco use supplement of the current population survey. Journal of Public Health, 2009; 32(2):210–8. Available from:  http://jpubhealth.oxfordjournals.org/content/32/2/210.full

16. 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

17. Lu Y, Tong S, and Oldenburg B. Determinants of smoking and cessation during and after pregnancy. Health Promotion International, 2001; 16(4):355–65. Available from:  http://heapro.oxfordjournals.org/cgi/content/full/16/4/355

18. Higgins S, Heil S, Badger G, Skelly J, Solomon L, et al. Educational disadvantage and cigarette smoking during pregnancy. Drug and Alcohol Dependence, 2009; 104(suppl 1.):100–5. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/19442460

19. Mohsin M and Bauman A. Socio-demographic factors associated with smoking and smoking cessation among 426,344 pregnant women in New South Wales, Australia. BMC Public Health, 2005; 5:138. Available from:  http://www.biomedcentral.com/content/pdf/1471-2458-5-138.pdf

20. Sellström E, Arnoldsson G, Bremberg S, and Hjern A. The neighbourhood they live in - does it matter to women's smoking habits during pregnancy? Health & Place, 2007; 14(2):155–66. Available from:  www.ncbi.nlm.nih.gov/pubmed/17616477

21. Flick L, Cook C, Homan S, McSweeney M, Campbell C, et al. Persistent tobacco use during pregnancy and the likelihood of psychiatric disorders. American Journal of Public Health, 2006; 96(10):1799−807. Available from:  http://www.ajph.org/cgi/content/abstract/96/10/1799

22. Australian Institute of Health and Welfare, Australia’s mothers and babies 2015—in brief. Perinatal statistics series no. 33. Cat no. Per 91 Canberra: AIHW; 2017. Available from:  https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-2015-in-brief/contents/table-of-contents .

23. Webb D, Culhane J, Mathew L, Bloch J, and Goldenberg R. Incident smoking during pregnancy and the postpartum period in a low-income urban population. Public Health Reports, 2011; 126(1):50–9. Available from:  www.ncbi.nlm.nih.gov/pubmed/21337931

24. Tran D, Roberts C, Jorm L, Seeho S, and Havard A. Change in smoking status during two consecutive pregnancies: A population-based cohort study. BJOG, 2014; 121(13):1611–20. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/24735217

25. Bain E, Guerin N, and White V. ASSAD 2017: The association between smoking and socioeconomic status among secondary school students in Australia. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2019.

26. King K, Martynenko M, Bergman MH, Liu Y-H, Winickoff JP, et al. Family composition and children's exposure to adult smokers in their homes. Pediatrics, 2009; 123(4):e559–64. Available from:  http://pediatrics.aappublications.org/cgi/content/full/123/4/e559

27. Alwan N, Siddiqi K, Thomson H, and Cameron I. Children's exposure to second-hand smoke in the home: A household survey in the north of England. Health & Social Care in the Community, 2009; 18(3):257–63. Available from:  www.ncbi.nlm.nih.gov/pubmed/20050935

28. Mantziou V, Vardavas C, Kletsiou E, and Priftis K. Predictors of childhood exposure to parental secondhand smoke in the house and family car. International Journal of Environmental Research and Public Health, 2009; 6:433–4. Available from:  http://www.mdpi.com/1660-4601/6/2/433/

29. Bolte G and Fromme H. Socioeconomic determinants of children's environmental tobacco smoke exposure and family's home smoking policy. European Journal of Public Health, 2008; 19(1):52–8. Available from:  http://eurpub.oxfordjournals.org/content/19/1/52.long

30. Adhikari P and Summerill A. 1998 National Drug Strategy Household Survey: Detailed findings. Drug statistics series no. 6, AIHW cat. no. PHE 27.Canberra: Australian Institute of Health and Welfare, 1999. Available from:  https://www.aihw.gov.au/reports/alcohol-other-drug-treatment-services/1998-ndshs-detailed-findings/contents/table-of-contents .

31. 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 .

32. Guydish J, Passalacqua E, Tajima B, and Manser S. Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: A review. Journal of Psychoactive Drugs, 2007; 39(4):23–33. Available from:  www.ncbi.nlm.nih.gov/pubmed/18303699

33. Johnson J, Malchy L, Ratner P, Hossain S, Procyshyn R, et al. Community mental healthcare providers' attitudes and practices related to smoking cessation interventions for people living with severe mental illness. Patient Education and Counseling, 2009; 77(2):289–95. Available from:  www.ncbi.nlm.nih.gov/pubmed/19398293

34. Ratschen E, Britton J, Doody GA, Leonardi-Bee J, and McNeill A. Tobacco dependence, treatment and smoke-free policies: A survey of mental health professionals' knowledge and attitudes. General Hospital Psychiatry, 2009; 31(6):576–82. Available from:  http://www.sciencedirect.com/science/journal/01638343

35. Stockings EA, Bowman JA, Bartlem KM, McElwaine KM, Baker AL, et al. Implementation of a smoke-free policy in an inpatient psychiatric facility: Patient-reported adherence, support, and receipt of nicotine-dependence treatment. International Journal of Mental Health Nursing, 2015; 24(4):342–9. Available from:  http://www.ncbi.nlm.nih.gov/pubmed/25970237