In Australia, the prevalence of smoking remains substantially higher among those with low educational attainment and lower income levels compared with the population as a whole (see Section 9.1). Smoking exacerbates financial stress and poverty both for adults,1 and children2—see Section 9.4. Australian socioeconomically disadvantaged smokers have reported frequent experiences of deprivation and financial stress caused by their smoking, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes.3 Several studies have found that increases in income support/wages among socioeconomically disadvantaged smokers are associated with increases in smoking cessation.4,5 Subsidised cessation medications are also associated with increased use among disadvantaged groups6 (see Section 9.9).
Social (e.g., low social support for quitting), psychological (e.g., low self-efficacy) and physical factors (e.g., greater nicotine dependence) all contribute to the higher tobacco use among socially disadvantaged populations7 (see Section 9.7). Qualitative research in Australia has found that socially disadvantaged populations may be resistant to cessation interventions and feel a lack of control over their smoking and the stressful life circumstances that sustain it. 8 Feelings of guilt, shame and stigma can impede help-seeking among low-socioeconomic status (low-SES) smokers in Australia.9 Nonetheless, the most disadvantaged smokers in Australia are equally likely to make a quit attempt (albeit with less success), and equally or more likely to use quit aids, as those more socioeconomically advantaged.10
The development of interventions that address smoking among low-SES groups is a high clinical and economic priority to reduce health inequalities and improve life expectancies,11 and to reduce the financial burden of smoking.2 However, a systematic review of research into cessation among low-SES and other disadvantaged groups concluded that the current research output is not ideal or optimal for guiding design of policies and programs to decrease smoking rates.11 Nonetheless, a recent review found consistent evidence that individual-level smoking cessation interventions in socioeconomically disadvantaged groups are effective.12 Examples of such interventions are outlined below. For a discussion of whether individual-level interventions increase (or decrease) disparities in smoking prevalence between low-SES and more advantaged groups, see Section 9.9. Population-wide strategies, including tax increases and narrative mass media campaigns, are also effective at reducing smoking among low-SES groups—see Section 9.8 for a detailed discussion.
9.6.1 Financial incentives
Several studies have examined the potential of offering low-SES smokers financial incentives to quit. A study in the US assessed two strategies (direct mail and opportunistic telephone referrals) that offered financial incentives to low-income smokers for being connected to a quitline. Both strategies successfully connected smokers to the Quitline and encouraged quit attempts and continuous smoking abstinence.13 Another US study similarly found that financial incentives encouraged Quitline use among socioeconomically disadvantaged smokers.14 There is evidence supporting the effectiveness of financial incentives that are large,15 and also modest incentives,16 as well as those that are not contingent on outcomes,17 for increasing engagement and quitting behaviours among low-income smokers.
See Section 7.17 for a detailed discussion of financial incentives for smoking cessation.
9.6.2 Telephone and Internet-based interventions
Studies have supported the use of the Quitline to support and promote quitting among low-SES smokers. A brief intervention comprising counselling, referral to the Quitline, and free nicotine replacement therapy resulted in quit attempts and successful quitting among low-income smokers visiting an emergency department.18 A trial in the US found that greater use of Quitline services was associated with higher abstinence in low-income smokers.19 While research in the US has suggested there may be barriers to using the Quitline among low-SES smokers such as not having access to a phone 20 and the cost of making the call from a mobile,21 low-SES smokers in Australia appear to be just as or more likely to contact the Quitline10, 22 (see Section 9.8). Australian research has also suggested that text messaging-based9 and internet-based interventions23 have potential for reducing smoking among low-SES smokers.
See Section 7.14 for a broader discussion of these interventions.
9.6.3 Role of healthcare providers and community organisations
Integrating interventions into community programs holds promise for promoting cessation among low-SES smokers.24-27 In the UK, stop-smoking services appear to reduce inequalities in smoking through increased relative reach through targeting services to low-SES smokers.28, 29 For example, one UK study found that a mobile, drop-in, community-based stop smoking service effectively increased reach to disadvantaged smokers.30 Two studies in the US have examined interventions among Salvation Army client smokers: one that showed that a brief, targeted motivational intervention increased the initiation of an evidence-based tobacco cessation treatment,31 and another that challenged beliefs about the effectiveness of various quit methods, which was associated with greater smoking reduction and greater likelihood of contacting the Quitline.32 Disadvantaged smokers in Australia report being open to receiving information and support to quit from community service organisations.33 Peer support interventions also appear to have potential to address the high prevalence of smoking in vulnerable populations, particularly among disadvantaged groups who experience fewer opportunities to access such support informally.7, 26, 34
Healthcare professionals can also play an important role in reducing smoking among disadvantaged populations by integrating cessation interventions into routine care.29 In Australia, GPs and other healthcare providers are a known and trusted source of cessation information and advice for disadvantaged people who smoke,33 and low-SES smokers are just as likely as mid-high-SES smokers to report being advised to quit by their doctor (see Section 9.8). Such interventions can promote and assist smoking cessation – see Section 7.10 for a broader discussion.
9.6.4 Increasing the effectiveness of cessation interventions
Tailoring and adapting evidence-based cessation treatments to address the needs of socioeconomically disadvantaged groups has been suggested as a pathway to increasing their effectiveness; however a recent review found that while individual-level interventions were effective, there were no differences in the effectiveness of socioeconomic-position-tailored and non-tailored cessation interventions for reducing smoking among disadvantaged groups. The authors suggesting that multifaceted approaches and improvements in current tailored interventions may be needed to reduce disparities.12 Several reviews have concluded that multicomponent cessation interventions are needed for low socioeconomic populations,35, 36 and have highlighted the importance of social support, employing community-based participatory approaches to develop tailored approaches, effective combination pharmacotherapies (varenicline and NRT),36 incentives, and peer facilitators.35
Despite being just as likely to make quit attempts, low-SES smokers experience less success in sustaining cessation.10 Increasing the likelihood that quit attempts are successful is therefore an important step in reducing smoking prevalence and smoking-related disparities. Low-income smokers are more likely to discontinue treatment early (see Section 18.104.22.168); therefore interventions that increase compliance may help to increase the success of quit attempts. 37 For example, interventions that enhance resilience,38 motivation, and self-efficacy39 and address life stressors.40 Providing greater choice/sampling of NRT41-43 can also help to promote adherence and cessation among low-SES smokers.
9.6.5 Increasing engagement with cessation interventions
Disadvantaged smokers have traditionally been a hard-to-reach group, and researchers have examined factors that could promote engagement with cessation interventions among socioeconomically disadvantaged populations. Targeting interventions in areas with high numbers of low SES smokers by healthcare and community organisations can help compensate for low SES smokers’ relatively low quit rate, thereby reducing health disparities.29 In Victoria, Quit is geotargeting several low-SES Local Government Areas with high numbers of smokers, with strategies including additional campaign messaging in outdoor and shopping locations, geotargeted messaging on social and digital media, and community organisations amplifying Quit’s messages. The project aims to increase smokers’ self-efficacy to quit and maintain cessation, as well as to educate and encourage those surrounding them (health professionals, family, friends) to provide support.44
To increase recruitment for smoking cessation trials, studies have found that mailed invitations and follow-up from health professionals,45 and in-person field-based methods,46, 47 appear to be effective strategies. Among disadvantaged smokers in Australia, one trial found that retention was higher among those with higher motivation to quit, more recent quit attempts, increased age, higher level of education and for those recruited through Quitline or newspaper advertisements.48 Proactively contacting smokers and offering cessation support, regardless of their interest in quitting, can also be effective in promoting quitting among socioeconomically disadvantaged smokers.14,49
Relevant news and research
For recent news items and research on this topic, click here.( Last updated January 2023)
1. Siahpush M, Borland R, and Scollo M. Smoking and financial stress. Tobacco Control, 2003; 12(1):60–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12612364
2. Belvin C, Britton J, Holmes J, and Langley T. Parental smoking and child poverty in the UK: an analysis of national survey data. BMC Public Health, 2015; 15:507. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26021316
3. Guillaumier A, Bonevski B, and Paul C. 'Cigarettes are priority': a qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices. Health Education Research, 2015; 30(4):599–608. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26116583
4. Du J and Leigh JP. Effects of wages on smoking decisions of current and past smokers. Annals of Epidemiology, 2015; 25(8):575–82 e1. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26066536
5. Fu W and Liu F. Unemployment insurance and cigarette smoking. J Health Econ, 2019; 63:34–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30453224
6. Milcarz K, Polanska K, Balwicki L, Makowiec-Dabrowska T, Hanke W, et al. Perceived barriers and motivators to smoking cessation among socially-disadvantaged populations in Poland. Int J Occup Med Environ Health, 2019; 32(3):363–77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31063158
7. Ford P, Clifford A, Gussy K, and Gartner C. A systematic review of peer-support programs for smoking cessation in disadvantaged groups. International Journal of Environmental Research and Public Health, 2013; 10(11):5507–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24169412
8. Pateman K, Ford P, Fizgerald L, Mutch A, Yuke K, et al. Stuck in the catch 22: attitudes towards smoking cessation among populations vulnerable to social disadvantage. Addiction, 2016; 111(6):1048–56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26615055
9. Boland VC, Mattick RP, McRobbie H, Siahpush M, and Courtney RJ. "I'm not strong enough; I'm not good enough. I can't do this, I'm failing"- A qualitative study of low-socioeconomic status smokers' experiences with accesssing cessation support and the role for alternative technology-based support. Int J Equity Health, 2017; 16(1):196. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29132364
10. Greenhalgh E, Bayly M, Brennan E, and Scollo M. The great socioeconomic smoking divide: is the gap widening in Australia, and why? Tobacco Prevention & Cessation, 2018; 4(Supplement). Available from: http://dx.doi.org/10.18332/tpc/90484
11. Courtney RJ, Naicker S, Shakeshaft A, Clare P, Martire KA, et al. Smoking Cessation among Low-Socioeconomic Status and Disadvantaged Population Groups: A Systematic Review of Research Output. International Journal of Environmental Research and Public Health, 2015; 12(6):6403–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26062037
12. Kock L, Brown J, Hiscock R, Tattan-Birch H, Smith C, et al. Individual-level behavioural smoking cessation interventions tailored for disadvantaged socioeconomic position: a systematic review and meta-regression. Lancet Public Health, 2019; 4(12):e628–e44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31812239
13. Slater JS, Nelson CL, Parks MJ, and Ebbert JO. Connecting low-income smokers to tobacco treatment services. Addictive Behaviors, 2016; 52:108–14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26489597
14. Parks MJ, Hughes KD, Keller PA, Lachter RB, Kingsbury JH, et al. Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial. Preventive Medicine, 2019; 129:105867. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31634512
15. Etter JF and Schmid F. Effects of large financial incentives for long-term smoking cessation: A randomized trial. J Am Coll Cardiol, 2016; 68(8):777–85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27539168
16. Kendzor DE, Businelle MS, Poonawalla IB, Cuate EL, Kesh A, et al. Financial incentives for abstinence among socioeconomically disadvantaged individuals in smoking cessation treatment. American Journal of Public Health, 2015; 105(6):1198–205. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25393172
17. Anderson CM, Cummins SE, Kohatsu ND, Gamst AC, and Zhu SH. Incentives and patches for Medicaid smokers: An RCT. American Journal of Preventive Medicine, 2018; 55(6 Suppl 2):S138–S47. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30454668
18. Mahabee-Gittens EM, Khoury JC, Ho M, Stone L, and Gordon JS. A smoking cessation intervention for low-income smokers in the ED. American Journal of Emergency Medicine, 2015; 33(8):1056–61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25976268
19. Bernstein SL, Weiss JM, Toll B, and Zbikowski SM. Association between utilization of quitline services and probability of tobacco abstinence in low-income smokers. Journal of Substance Abuse Treatment, 2016; 71:58–62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27776679
20. Sheffer C, Brackman S, Lercara C, Cottoms N, Olson M, et al. When Free Is Not for Me: Confronting the Barriers to Use of Free Quitline Telephone Counseling for Tobacco Dependence. International Journal of Environmental Research and Public Health, 2015; 13(1):ijerph13010015. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26703662
21. Bernstein SL, Rosner JM, and Toll B. Cell phone ownership and service plans among low-income smokers: The hidden cost of quitlines. Nicotine & Tobacco Research, 2016; 18(8):1791–3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26920647
22. Greenhalgh E and Scollo M. Quitting behaviours and use of cessation aids among priority groups in Victoria: Results from the 2018–2019 Victorian Smoking and Health Survey. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2021.
23. McCrabb S, Twyman L, Palazzi K, Guillaumier A, Paul C, et al. A cross sectional survey of internet use among a highly socially disadvantaged population of tobacco smokers. Addiction Science & Clinical Practice, 2019; 14(1):38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31610808
24. Levinson AH, Valverde P, Garrett K, Kimminau M, Burns EK, et al. Community-based navigators for tobacco cessation treatment: a proof-of-concept pilot study among low-income smokers. BMC Public Health, 2015; 15(1):627. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26155841
25. Moody-Thomas S, Sparks M, Hamasaka L, Ross-Viles S, and Bullock A. The head start tobacco cessation initiative: using systems change to support staff identification and intervention for tobacco use in low-income families. Journal of Community Health, 2014; 39(4):646–52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24532307
26. Andrews JO, Mueller M, Dooley M, Newman SD, Magwood GS, et al. Effect of a smoking cessation intervention for women in subsidized neighborhoods: A randomized controlled trial. Preventive Medicine, 2016; 90:170–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27423320
27. Specktor C and Keller PA. Creating culturally-specific and community-specific approaches to linking low socioeconomic smokers to cessation services. Journal of Health Care for the Poor and Underserved, 2019; 30(3):934–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31422980
28. Brown T, Platt S, and Amos A. Equity impact of European individual-level smoking cessation interventions to reduce smoking in adults: a systematic review. European Journal of Public Health, 2014; 24(4):551–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24891458
29. Smith C, Hill S, and Amos A. Stop Smoking Inequalities: A systematic review of socioeconomic inequalities in experiences of smoking cessation interventions in the UK. Cancer Research UK, 2018. Available from: https://www.cancerresearchuk.org/sites/default/files/stop_smoking_inequalities_2018.pdf
30. Venn A, Dickinson A, Murray R, Jones L, Li J, et al. Effectiveness of a mobile, drop-in stop smoking service in reaching and supporting disadvantaged UK smokers to quit. Tobacco Control, 2016; 25(1):33–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25260749
31. Christiansen BA, Reeder KM, TerBeek EG, Fiore MC, and Baker TB. Motivating low socioeconomic status smokers to accept evidence-based smoking cessation treatment: A brief intervention for the community agency setting. Nicotine & Tobacco Research, 2015; 17(8):1002–11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26180226
32. Christiansen B, Reeder K, Fiore MC, and Baker TB. Changing low income smokers' beliefs about tobacco dependence treatment. Substance Use and Misuse, 2014; 49(7):852–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24502374
33. Parnell A, Box E, Bonevski B, Slevin T, Anwar-McHenry J, et al. Potential sources of cessation support for high smoking prevalence groups: a qualitative study. Australian and New Zealand Journal of Public Health, 2019; 43(2):108–13. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30673149
34. Meijer E, Gebhardt WA, Van Laar C, Kawous R, and Beijk SC. Socio-economic status in relation to smoking: The role of (expected and desired) social support and quitter identity. Social Science & Medicine, 2016; 162:41–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27328056
35. Smith P, Poole R, Mann M, Nelson A, Moore G, et al. Systematic review of behavioural smoking cessation interventions for older smokers from deprived backgrounds. BMJ Open, 2019; 9(11):e032727. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31678956
36. Huynh N, Tariq S, Charron C, Hayes T, Bhanushali O, et al. Personalised multicomponent interventions for tobacco dependence management in low socioeconomic populations: a systematic review and meta-analysis. Journal of Epidemiology and Community Health, 2022. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35623792
37. Ma P, Kendzor DE, Poonawalla IB, Balis DS, and Businelle MS. Daily nicotine patch wear time predicts smoking abstinence in socioeconomically disadvantaged adults: An analysis of ecological momentary assessment data. Drug and Alcohol Dependence, 2016; 169:64–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27776246
38. Tsourtos G, Foley K, Ward P, Miller E, Wilson C, et al. Using a nominal group technique to approach consensus on a resilience intervention for smoking cessation in a lower socioeconomic population. BMC Public Health, 2019; 19(1):1577. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31775709
39. Lepore SJ, Collins BN, and Sosnowski DW. Self-efficacy as a pathway to long-term smoking cessation among low-income parents in the multilevel Kids Safe and Smokefree intervention. Drug and Alcohol Dependence, 2019; 204:107496. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31499240
40. Hiscock R, Bauld L, Amos A, Fidler JA, and Munafo M. Socioeconomic status and smoking: a review. Annals of the New York Academy of Sciences, 2012; 1248:107–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22092035
41. Cropsey KL, Wolford-Clevenger C, Sisson ML, Chichester KR, Hugley M, et al. A pilot study of nicotine replacement therapy sampling and selection to increase medication adherence in low-income smokers. Nicotine & Tobacco Research, 2021; 23(9):1575–83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33608735
42. Dahne J, Wahlquist AE, Smith TT, and Carpenter MJ. The differential impact of nicotine replacement therapy sampling on cessation outcomes across established tobacco disparities groups. Preventive Medicine, 2020; 136:106096. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32320705
43. Heron M, Le Faou AL, Ibanez G, Metadieu B, Melchior M, et al. Smoking cessation using preference-based tools: a mixed method pilot study of a novel intervention among smokers with low socioeconomic position. Addiction Science & Clinical Practice, 2021; 16(1):43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34193288
44. Quit Victoria. Sponge & Quite a difference: Geotargeting campaign 2022 toolkit. 2022. Available from: https://www.quit.org.au/articles/sponge-quite-difference-geotargeting-campaign-2022-toolkit/#anchor-name.
45. Thompson TP, Greaves CJ, Ayres R, Aveyard P, Warren FC, et al. Lessons learned from recruiting socioeconomically disadvantaged smokers into a pilot randomized controlled trial to explore the role of Exercise Assisted Reduction then Stop (EARS) smoking. Trials, 2015; 16(1):1. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25971836
46. Greiner Safi A, Reyes C, Jesch E, Steinhardt J, Niederdeppe J, et al. Comparing in person and internet methods to recruit low-SES populations for tobacco control policy research. Social Science & Medicine, 2019; 242:112597. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31670216
47. van Straaten B, Meerkerk GJ, van den Brand FA, Lucas P, de Wit N, et al. How can vulnerable groups be recruited to participate in a community-based smoking cessation program and perceptions of effective elements: A qualitative study among participants and professionals. Tob Prev Cessat, 2020; 6:64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33241164
48. Courtney RJ, Clare P, Boland V, Martire KA, Bonevski B, et al. Predictors of retention in a randomised trial of smoking cessation in low-socioeconomic status Australian smokers. Addictive Behaviors, 2017; 64:13–20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27533077
49. Fu SS, van Ryn M, Nelson D, Burgess DJ, Thomas JL, et al. Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial. Thorax, 2016; 71(5):446–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26931362