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

Last updated: September 2021
Suggested citation: Greenhalgh, EM, Puljevic, C, Jenkins, S, & Scollo, M. 9.6 Smoking, ill-health, financial stress and smoking-related poverty among highly disadvantaged groups. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021.  Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-6-smoking-ill-health-financial-stress-and-smokin

 

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

In addition to the disparities in smoking among broad categories of socio-economic status, smoking rates are even higher among many groups of highly disadvantaged people.  These include: 

9.6.1 People living in regional and remote areas of Australia

9.6.2 People born overseas

9.6.3 Lone parents, especially lone mothers

9.6.4 People with mental and substance use disorders

9.6.5 The homeless

9.6.6 Prison populations

9.6.7 Veterans

See Chapter 7, Section 7.19 for a detailed overview of targeted cessation interventions for the groups mentioned above and additional groups with very high smoking prevalence, including low-income groups and lesbian, gay, bisexual, and transgender (LGBT) people. Chapter 8 provides a full discussion of smoking among Aboriginal and Torres Strait Islander people. 

9.6.1 People living in regional and remote areas of Australia

In 2014, about 29% of Australians lived outside major cities; 26.9% in regional areas and 2.3% in remote or very remote areas.1  

In 2014–15, people living in outer regional and remote areas had higher rates of daily smoking (20.9%) than people in inner regional areas (16.7%) or major cities (13.0%). Prevalence has declined among all groups over time; however, the current rate for people living in outer regional and remote areas is about the same as that of major cities a decade ago.2  They also report higher rates of smoking-related diseases, such as arthritis, asthma, COPD, diabetes, and cardiovascular disease, and are more likely to experience psychological distress and to report suffering a mental disorder.2 Life expectancy decreases with increasing remoteness. In 2009–2011, people living in remote and very remote areas had mortality rates 1.4 times as high as people living in major cities.1   

Compared with people in regional areas and major cities, those living in remote and very remote areas often have poorer access to, and use of, health care services. They are also less likely to participate in breast and bowel cancer screening, have higher rates of potentially avoidable hospitalisations, and lower access to selected hospital procedures.1  Because health professionals are in such short supply in rural and remote areas, it is often difficult to prioritise 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.3  

The 2012–18 National Tobacco Strategy outlines a number of aims to reduce smoking among priority populations, including those living in regional and remote areas. These include population-based approaches such as social marketing campaigns, tax increases, and smokefree legislation, as well as ensuring access to individual cessation support, such as Quitline services, online services, specialised services, and brief interventions by health professionals.4  Subsidies of cessation medications also aim to increase use and access.4  Since 2011, all Australians have been able to access subsidised over-the-counter nicotine replacement therapy patches. Bupropion and varenicline are only available on prescription, but have been available on Australia’s PBS since 2001 and 2008 respectively (see Section 7.16). 

9.6.2 People born overseas

In 2014–15, people born overseas comprised 28 per cent of Australia's population. The highest proportion were born in the UK (5.1%), followed by New Zealand (2.6%), and China (2.0%).5  Immigrant populations generally enjoy better reported health and lower rates of disability and hospitalisation than those reported by people born in Australia.6  Nonetheless, rates of mortality for some diseases are higher in some immigrant groups compared to 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.7, 8  Participation in preventative health care, such as cancer screening, is also lower among some culturally and linguistically diverse groups.1   

Generally speaking, people born outside of Australia are less likely to be smokers than those born in Australia. Similarly, the prevalence of smoking is higher in English-speaking households compared with those that mainly speak a language other than English (See Chapter 1, Section 1.8). Nonetheless, among some population sub-groups, smoking is much more common. For example, small studies have found that as many as half of men with Chinese or Vietnamese backgrounds in Australia are smokers.9, 10  A study of Arabic-speaking patients seen in the general practice setting in New South Wales found that almost one third were smokers. Smokers were also more likely to report poorer overall health and high nicotine dependence. Nicotine dependence was highest in Arabic-speaking males.11  A study of Australians over 45 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.12  Smoking rates among women immigrants from non-Western countries (where smoking is typically rare) may also increase as they acculturate and adopt new social norms.13  Morbidity and mortality from smoking-related diseases can therefore disproportionately affect culturally and linguistically diverse (CALD) populations.14 

Among children, a Canadian study of overseas-born children found that the likelihood of smoking increased with the years spent living in Canada.15  A similar finding was made in the US, where the odds of ever use of tobacco among Hmong American youth increased the longer they had spent living in the US.16  In Australia, the risk of smoking appears to increase among women born in Asia the younger they had migrated.12

People from cultural backgrounds where smoking is highly prevalent may face cultural resistance and unique barriers to quitting.17, 18  Providing education and support to Australians with different cultural backgrounds provides particular challenges for public health policy.19  For an overview of cessation interventions for people from culturally and linguistically diverse backgrounds, see Section 7.19.7.

9.6.3 Lone parents, especially lone mothers

The prevalence of smoking in single-parent households is significantly higher than among those with two parents, with single mother families making up the vast majority of one parent families. (See Chapter 1, Section 1.10.3)  Lone mothers and their children are one of the most disadvantaged groups in many countries20  and suffer higher risks of poverty and ill-health than other family structures.21, 22  Lone parents tend to have higher levels of unemployment, in part due to caring responsibilities, and are more likely to experience financial hardship.23, 24

In Australia in 2009–10, three in five (59%) lone parent households with dependent children were classified as having ‘low economic resources’. One-parent households accounted for 6% of all households, but comprised 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.26  In comparison, coupled households with dependent children spent $11.86 per week.26

Australian research conducted in the early 2000s found that almost half (46%) of lone mothers reported smoking, with those younger in age (18–29 years) reporting the highest prevalence (59%).27  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 and twice as large as those for women living alone.28   Smoking among lone mothers is associated both with present29  and long-term challenges caused by disadvantage.30-37  Poorer coping styles and self-blame are also associated with higher rates of smoking among this group.38

Lone mothers are much less likely than mothers with partners to quit smoking during pregnancy. Further, mothers who continue to smoke during pregnancy are more likely to report having a difficult, fussy baby, adding to the stress of child raising without a partner present. 39, 40   

In 2019, the National Drug Strategy Household Survey reported current smoking prevalence in single-parent households with dependent children was 29.9%, more than double the prevalence in coupled households with dependent children (12.2%). Lone parent households also reported higher consumption, with an average of 101 cigarettes smoked per week, compared to an average of 83 cigarettes per week in coupled households with children (Table 8.21).41

Australian research found that 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.42   

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

Source: Gartner and Hall (2012)41

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

Children who live in households with a smoker suffer more often and more severely from respiratory diseases.43, 44 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,45-47 therefore smoking can lead to multiple generations of health and social disadvantage.

9.6.4 People with mental and substance use disorders

Mental and substance use disorders are the third leading ‘broad cause’ of Australia’s disease burden, behind cancer and cardiovascular disease.48 The 2007 National Survey of Mental Health and Wellbeing reported that 45% of Australians aged 16–85 will experience a high prevalence mental disorder, such as depression, anxiety, or a substance use disorder in their lifetime.8  Compared with the general population, people with mental illness have higher smoking rates, higher levels of nicotine dependence, and a disproportionate health and financial burden from smoking.49, 50 In Australia in 2019, daily smokers were twice as likely to have high/very high levels of psychological distress compared with people who had never smoked (25.1% compared with 12.3%, respectively) and were twice as likely to have been diagnosed or treated for a mental health condition (29% compared with 14%)(Table 2.60).51

Smokers with co-occurring mental illness or substance use disorders have limited access to cessation treatment, longer durations of smoking, and lower rates of quitting. They also have shortened life expectancies, largely due to smoking-related disease; such smokers are far more likely to die from their smoking than as a result of their psychiatric condition.49, 52  People with mental illness and mental health workers often perceive smoking to be helpful in relieving or managing psychiatric symptoms.53, 54 However, recent evidence suggests that the reverse is true; quitting smoking for at least six weeks actually improves mental health, mood, and quality of life, both among the general population and among people with a psychiatric disorder.53   

Smoking can also exacerbate financial stress among people with mental illness. 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. Smoking plays an important role in the cycle of poverty and disadvantage experienced by people with mental illness.55

Chapter 7, Section 12 provides a detailed overview of smoking and mental health, including prevalence, factors influencing uptake and barriers to quitting, cessation interventions, and the role of health professionals. 

9.6.5 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 to 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 to those who had never been homeless (22% compared to 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.56  Melbourne-based research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%.56

For a detailed overview of smoking among homeless people and targeted cessation interventions, see Chapter 7, Section 7.19.3.

9.6.6 Prison populations

Last updated September 2021

In June 2020, there were about 41,000 adult prisoners in Australia; 92% of prison entrants at this time were men.57 In June 2018, about two in three (66%–69%) prison entrants aged 18–44 were daily smokers, compared with just one in seven (14%–16%) people in the general community.58 The primary reason for high rates of smoking among this population is that smoking is common among groups over-represented in the prison population, including those of lower socioeconomic status, Aboriginal and Torres Strait Islander peoples, people with mental health disorders, people with substance use disorders, and people experiencing homelessness.59  For example, in 2019, Aboriginal and Torres Strait Islander prisoners accounted for just over a quarter (28%) of the total prisoner population (while only comprising 2.8% of the Australian population).60, 61 Tobacco use has historically been commonly accepted as part of prison life, 62 serving a variety of purposes such as a form of currency,63, 64 a stress or boredom reliever,64-68 or a common ground for socialising.69 Other reasons for these high smoking rates among prisoners include a lack of smoking cessation programs in prisons (as well as an overall lack of these programs in the community), a lack of evidence regarding best practice for smoking cessation in this population group, and confusion over ownership of the issue between health departments and custodial authorities.66

Prisoners experience poorer physical and mental health than the general population. In 2018, almost one-third (29%) of Australian prison entrants reported a long-term health condition or disability that limited their daily activities and/or affected their participation in education or employment. A similar proportion (30%) reported having a chronic condition. Smoking-related illnesses such as asthma, cardiovascular disease, diabetes, and cancer were among the most common conditions. Almost one-quarter (22%) of entrants reported ever having been diagnosed with asthma, compared with 11% of the general population. A total of 40% of prison entrants reported ever having been told they have a mental health disorder, including alcohol and drug misuse.59 See Chapter 7, Section 7.12  for a detailed overview of the relationship between smoking and mental illness, as well as alcohol and substance use disorders, and Chapter 1, Section 1.10.6 for other drug use.

Epidemiological studies confirm that people who have been in prison experience higher rates of smoking-related illness, including various forms of cancer,70-73 hypertension,71 liver disease,70 asthma,71  and cardiovascular disease,74 further exacerbating their already increased levels of mortality and morbidity when compared to the general population.75-77 A study of over 85,000 people released from New South Wales prisons between 1988 and 2002 found a significantly higher rate of death from smoking-related cancers compared to the general community.72 Similarly, a study conducted in all state prisons in the US in 2014 found significantly higher age-adjusted smoking attributable mortality and potential life years lost as a result of tobacco smoking when compared to the non-incarcerated population.74

Prior to entering prison, many inmates had experienced lifetime exposure to cigarette smoking through their primary caregivers and friends.78 The average age at which Australian prison entrants had their first cigarette was 14,59 compared with 17 in the general population.51 A 2016 qualitative study in the US found many prisoners who smoked reported not having been taught by their family members about the dangers of smoking, rather it was more common that these family members themselves were smokers.78 One study found an association between heavy smoking among prisoners and past adverse childhood events such as alcoholism in the family, a psychiatric condition in the family, physical abuse, parental neglect and parental divorce.79 Factors within the prison environment that can increase prisoners’ likelihood of smoking include stress, boredom, lack of social support, high smoking rates among prisoners and staff, shared cells, relationship building between prisoners, and the use of tobacco as currency.80

As at February 2020, all Australian territories and states (except Western Australia) had introduced or announced intentions to introduce complete smoking bans in prisons. International studies have found that these bans are effective at improving the health of people who live and work in prisons.75, 81-84 For example, a survey of all state prisons in the US found a 9% reduction in smoking-related deaths in prisons that had implemented a smoking ban, and prisons with bans in place for longer than nine years showed an 11% reduction in all smoking-related deaths, a 19% decrease in deaths from cancer, and a 34% reduction in deaths with pulmonary causes.75 Other studies have found that these bans result in improved air quality,85-89 reduced exposure to harmful second-hand smoke,90, and decreased in-prison dispensing of medication for smoking-related illnesses 91 However, upon release from smokefree prisons, prison dischargees have a high and rapid rate of smoking relapse.92 A 2016 qualitative study78 from the US found many transitional housing facilities were not smokefree properties, and dischargees from smokefree prisons would relapse due to cigarettes being readily available in these environments. Family members also play an important role in whether prison dischargees are able to remain smoke-free upon release. Seventy per cent of study participants said having family members who smoked influenced their own smoking behaviours during the re-entry process.78

 See Section 7.19.10  for a discussion of smoking bans and other cessation interventions among prison populations.

9.6.7 Military personnel and veterans

Military personnel are more likely to smoke, and to smoke more heavily, than civilians.93-96 Australian research published in 2010 found that the highest prevalence of current smoking in the Australian Defence Force was among individuals with lower levels of education and those serving in the Navy (26%). The percentage of current smokers in the Army was 22% and the lowest prevalence of smokers was in the Air Force (8%).97 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.98 Tobacco use has traditionally been a part of defence force culture, with tobacco being provided and promoted to troops.99-102

Stress and trauma associated with war deployment is associated with the uptake of smoking, relapse, and overall high rates of smoking compared to the general population.103-105 The misperception that tobacco is effective for stress relief is pervasive among military personnel, including leaders.106 A study of returned veterans from the Iraq and Afghanistan wars indicated an association between heavy daily smoking and emotional numbing, suggesting that veterans suffering post-traumatic stress may smoke in an attempt to manage their trauma.107 US research has found that deployment with combat experience predicted higher smoking initiation and relapse rate among military personnel. Previous mental health disorders, life stressors, and other military and non-military characteristics also predicted initiation and relapse.108 Smoking is also associated with pain109  and alcohol use105 among veterans.

Veterans report poorer health and wellbeing than the general community. A 2006 survey of Australia’s Department of Veterans’ Affairs community found that older clients (65 years plus) were less likely to rate their health as very good or excellent compared with general community aged 65 or over (21% compared to 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 to 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 conditions were post-traumatic stress disorder, anxiety, substance abuse, and depression.8  One study of Australian Army Vietnam veterans concluded that the increased risk of mortality among these veterans is likely to be attributable to health-risk behaviours such as smoking, inactivity, and poor diet, rather than from war service per se or psychiatric disorder.110 Scottish research found an increased risk of smoking-related cancer compared with non-veterans among older veterans.93

Studies of US war veterans have concluded that additional effort is required to support smoking cessation in this community of particularly high smoking prevalence.95, 96, 111 Despite its longstanding role within military culture, there have been increasing efforts in recent years to implement tobacco control policies and cessation programs within the military. Strong policies and support by leaders appear crucial to the success of such interventions.112 For an overview of cessation interventions for veteran populations, see Chapter 7, Section 7.19.11

 

 

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References for Section 9.6

 

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