9.7 Explanations of socio-economic disparities in smoking

Last updated: December 2016 

Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.7 Explanations of socio-economic disparities in smoking. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-7-explanations-of-socioeconomic-disparities-in-s

'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, economic, commercial, and cultural factors,2  including:


  • nicotine exposure in utero and during childhood3-6
  • parental and peer relationships and modelling7-15
  • poorer academic achievement and lower school satisfaction16
  • anxiety and depression17-20  
  • social isolation21
  • for minority groups, experiencing discrimination.22, 23
  • a lesser tendency to consider and value future outcomes24-27  
  • the endorsement of beliefs that minimise or discount the risks of smoking28
  • workplaces29 and social circles30 that normalise smoking
  • job loss31 and financial stress32
  • a lower likelihood of working indoors33-35  
  • representations of smoking in popular culture36-39 
  • a history of targeted and intensive marketing40-44 


The above factors vary in importance in explaining socio-economic disparities at different developmental stages45  and at different stages in the tobacco addiction cycle.145 As with other aspects of social disadvantage, many factors driving tobacco-related disparities originate in childhood46-51 and accumulate throughout the individual’s life.1485253   

While a wealth of information is available on associations between social disadvantage and tobacco use,54-56 understanding the causal mechanisms underlying these associations is more challenging.57

An analysis of data from the 1995 Australian National Health Survey showed that 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. Geographic socio-economic disadvantage had a stronger association with smoking than individual level factors (education and income), highlighting the importance of the person’s social environment to smoking behaviours.58   

A longitudinal study of the health, development and adjustment of a cohort of New Zealand children concluded that 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%).59

Figures 9.7.1 and 9.7.2 show how a variety of physiological, psychological and sociological factors may 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.

Relevant news and research

For recent news items and research on this topic, click here.(Last updated April 2022)


1. Gilman SE, Abrams DB, and Buka SL. Socioeconomic status over the life course and stages of cigarette use: Initiation, regular use, and cessation. Journal of Epidemiolgy and Community Health, 2003; 57(10):802–8. Available from: http://jech.bmj.com/cgi/content/abstract/57/10/802 

2. Siahpush M. Why is lone motherhood so strongly associated with smoking in Australia? Australian and New Zealand Journal of Public Health, 2004; 28(1):37–42. Available from: http://www3.interscience.wiley.com/journal/118803451/abstract

3. Macleod J, Hickman M, Bowen E, Alati R, Tilling K, et al. Parental drug use, early adversities, later childhood problems and children's use of tobacco and alcohol at age 10: Birth cohort study. Addiction, 2008; 103(10):1731–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18705686

4. 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

5. Hanson M and Chen E. Socioeconomic status and health behaviors in adolescence: A review of the literature. Journal of Behavioral Medicine, 2007; 30(3):263–85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17514418

6. Hayatbakhsh M, Mamun A, Najman J, O'Callaghan M, Bor W, et al. Early childhood predictors of early substance use and substance use disorders: Prospective study. Australian and New Zealand Journal of Psychiatry, 2008; 42(8):720–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18622780

7. Richter M, Vereecken C, Boyce W, Maes L, Gabhainn S, et al. Parental occupation, family affluence and adolescent health behaviour in 28 countries. International Journal of Public Health, 2009; 54(4):203–12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19347249

8. Rainio S, Rimpelä A, Luukkaala T, and Rimpelä M. Evolution of the association between parental and child smoking in Finland between 1977 and 2005. Preventive Medicine, 2008; 46(6):565–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18289657

9. Paul SL, Blizzard L, Patton GC, Dwyer T, and Venn A. Parental smoking and smoking experimentation in childhood increase the risk of being a smoker 20 years later: The childhood determinants of adult health study. Addiction, 2008; 103(5):846–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18412765

10. Audrain-McGovern J, Rodriguez D, Tercyak KP, Neuner G, and Moss HB. The impact of self-control indices on peer smoking and adolescent smoking progression. Journal of Pediatric Psychology, 2006; 31(2):139–51. Available from: http://jpepsy.oxfordjournals.org/cgi/content/abstract/31/2/139 

11. Melchior M, Chastang J, Mackinnon D, Galera C, and Fombonne E. The intergenerational transmission of tobacco smokingthe role of parents' long-term smoking trajectories. Drug and Alcohol Dependence, 2009; 107(2–3):257–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20004064

12. Brook JS, Morojele NK, Brook DW, Zhang C, and Whiteman M. Personal, interpersonal, and cultural predictors of stages of cigarette smoking among adolescents in johannesburg, South Africa. Tobacco Control, 2006; 15(suppl. 1):i4853. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_1/i48 

13. Fraga S, Sousa S, Ramos E, Dias I, and Barros H. Social representations of smoking behaviour in 13yearold adolescents. Rev Port Pneumol, 2011; 17(1):2731. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21251481

14. Kim MJ, Fleming CB, and Catalano RF. Individual and social influences on progression to daily smoking during adolescence. Pediatrics, 2009; 124(3):895–902. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891669/

15. DiNapoli P. Early initiation of tobacco use in adolescent girls: Key sociostructural influences. Applied Nursing Research : ANR, 2009; 22(2):126–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19427575

16. Moor I, Rathmann K, Lenzi M, Pfortner TK, Nagelhout GE, et al. Socioeconomic inequalities in adolescent smoking across 35 countries: A multilevel analysis of the role of family, school and peers. European Journal of Public Health, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25713016

17. Strong D, Cameron A, Feuer S, Cohn A, Abrantes A, et al. Single versus recurrent depression history: Differentiating risk factors among current US smokers. Drug and Alcohol Dependence, 2010; 109(13):905. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20074868

18. Trosclair A and Dube S. Smoking among adults reporting lifetime depression, anxiety, anxiety with depression, and major depressive episode, United States, 2005-2006. Addictive Behaviors, 2009; 35(5):438–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20079577

19. Khaled SM, Bulloch A, Exner DV, and Patten SB. Cigarette smoking, stages of change, and major depression in the Canadian population. Canadian Journal of Pyschiatry, 2009; 54(3):204–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19321025

20. Cougle J, Zvolensky M, Fitch K, and Sachs-Ericsson N. The role of comorbidity in explaining the associations between anxiety disorders and smoking. Nicotine & Tobacco Research, 2010; 12(4):355–64. Available from: http://ntr.oxfordjournals.org/content/12/4/355.long

21. Shareck M, Kestens Y, and Frohlich KL. Moving beyond the residential neighborhood to explore social inequalities in exposure to area-level disadvantage: Results from the interdisciplinary study on inequalities in smoking. Social Science & Medicine, 2014; 108:106–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24632055

22. Parker LJ, Kinlock BL, Chisolm D, Furr-Holden D, and Thorpe RJ, Jr. Association between any major discrimination and current cigarette smoking among adult African American men. Substance Use and Misuse, 2016:1–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27484877

23. Agunwamba AA, Kawachi I, Williams DR, Finney Rutten LJ, Wilson PM, et al. Mental health, racial discrimination, and tobacco use differences across rural-urban California. Journal of Rural Health, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27074968

24. Khwaja A, Silverman D, and Sloan F. Time preference, time discounting, and smoking decisions. Journal of Health Economics, 2007; 26(5):927–49. Available from: http://www.nber.org/papers/w12615

25. VanderVeen JW, Cohen LM, Cukrowicz KC, and Trotter DR. The role of impulsivity on smoking maintenance. Nicotine & Tobacco Research, 2008; 10(8):1397–404. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18686188

26. Businelle M, McVay M, Kendzor D, and Copeland A. A comparison of delay discounting among smokers, substance abusers, and non-dependent controls. Drug and Alcohol Dependence, 2010; 112(3):24750. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20696538

27. Fields S, Leraas K, Collins C, and Reynolds B. Delay discounting as a mediator of the relationship between perceived stress and cigarette smoking status in adolescents. Behavioural Pharmacology, 2009; 20(5–6):455–60. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19730366

28. Guillaumier A, Bonevski B, Paul C, D'Este C, Twyman L, et al. Self-exempting beliefs and intention to quit smoking within a socially disadvantaged Australian sample of smokers. International Journal of Environmental Research and Public Health, 2016; 13(1). Available from: http://www.ncbi.nlm.nih.gov/pubmed/26761022

29. Sorensen G, Emmons K, Stoddard AM, Linnan L, and Avrunin J. Do social influences contribute to occupational differences in quitting smoking and attitudes toward quitting? American Journal of Health Promotion, 2002; 16(3):135–41. Available from: http://ahp.sagepub.com/content/16/3/135.abstract

30. Hitchman SC, Fong GT, Zanna MP, Thrasher JF, Chung-Hall J, et al. Socioeconomic status and smokers' number of smoking friends: Findings from the International Tobacco Control (ITC) Four Country Survey. Drug and Alcohol Dependence, 2014; 143:158–66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25156228

31. Golden SD and Perreira KM. Losing jobs and lighting up: Employment experiences and smoking in the great recession. Social Science & Medicine, 2015; 138:110–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26079992

32. Twyman L, Bonevski B, Paul C, Bryant J, West R, et al. Factors associated with concurrent tobacco smoking and heavy alcohol consumption within a socioeconomically disadvantaged Australian sample. Substance Use and Misuse, 2016; 51(4):459–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26942661

33. Smith DR. Tobacco smoking by occupation in Australia and the United States: A review of national surveys conducted between 1970 and 2005. Industrial Health 2008; 46:77–89. Available from: http://www.jstage.jst.go.jp/article/indhealth/46/1/46_77/_article

34. Smith D and Leggat P. Tobacco smoking by occupation in Australia: Results from the 2004 to 2005 National Health Survey. Journal of Occupational and Environmental Medicine, 2007; 49(4):437–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17426527

35. 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.

36. Martyn CN. Smoking in British popular culture 1800-2000. British Medical Journal, 2000; 321(7257):389. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10926605

37. Krupka LR, Vener AM, and Richmond G. Tobacco advertising in gender-oriented popular magazines. J Drug Educ, 1990; 20(1):1529. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2348303

38. Healton CG, Watson-Stryker ES, Allen JA, Vallone DM, Messeri PA, et al. Televised movie trailers: Undermining restrictions on advertising tobacco to youth. Archives of Pediatrics & Adolescent Medicine, 2006; 160(9):8858. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16953010

39. Soulos G and Sanders S. Promoting tobacco to the young in the age of advertising bans. N S W Public Health Bulletin, 2004; 15(56):1046. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15543244

40. John R, Cheney MK, and Azad MR. Point-of-sale marketing of tobacco products: Taking advantage of the socially disadvantaged? Journal of Health Care for the Poor and Underserved, 2009; 20(2):489–506. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19395844

41. Apollonio DE and Malone RE. Marketing to the marginalised: Tobacco industry targeting of the homeless and mentally ill. Tobacco Control, 2005; 14(6):409–15. Available from: http://tc.bmjjournals.com/cgi/content/abstract/14/6/409 

42. Siahpush M, Jones PR, Singh GK, Timsina LR, and Martin J. The association of tobacco marketing with median income and racial/ethnic characteristics of neighbourhoods in Omaha, Nebraska. Tobacco Control, 2010; 19(3):256–8. Available from: http://tobaccocontrol.bmj.com/content/19/3/256.abstract 

43. Siahpush M, Jones P, Singh G, Timsina L, and Martin J. Association of availability of tobacco products with socio-economic and racial/ethnic characteristics of neighbourhoods. Public Health, 2010; 124(9):5259. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20723950

44. Brown-Johnson CG, England LJ, Glantz SA, and Ling PM. Tobacco industry marketing to low socioeconomic status women in the USA. Tobacco Control, 2014; 23(e2):e139–46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24449249

45. Moolchan ET, Fagan P, Fernander A, Velicer W, Hayward MD, et al. Addressing tobacco-related health disparities. Addiction, 2007; 102 (suppl. 2):30–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17850612

46. Brunner E, Shipley M, Blane D, and al e. When does cardiovasular risk start? Past and present socioeconomic circumstances and risk factors in adulthood. Journal of Epidemiology and Community Health, 1999; 53(12):757–64. Available from: http://jech.bmj.com/cgi/reprint/53/12/757

47. Power C, Graham H, Due P, Hallqvist J, Joung I, et al. The contribution of childhood and adult socioeconomic position to adult obesity and smoking behaviour an international comparison. International Journal of Epidemiology, 2005; 34(2):344–55. Available from: http://ije.oxfordjournals.org/cgi/content/full/34/2/335

48. Galobardes B, Lynch J, and Smith DG. Childhood socioeconomic circumstances and cause-specific mortality in adulthood: Systematic review and interpretation. Epidemiologic Reviews, 2004; 26(1):7–21. Available from: http://epirev.oxfordjournals.org/cgi/content/full/26/1/7

49. Harville E, Boynton-Jarrett R, Power C, and Hypponen E. Childhood hardship, maternal smoking, and birth outcomes: A prospective cohort study. Archives of Pediatrics & Adolescent Medicine, 2010; 164(6):533–9. Available from: http://archpedi.ama-assn.org/cgi/content/full/164/6/533

50. Evans G and Kutcher R. Loosening the link between childhood poverty and adolescent smoking and obesity: The protective effects of social capital. Psychological Science, 2010; 22(1):37. Available from: http://pss.sagepub.com/content/22/1/3.long

51. Topitzes J, Mersky JP, and Reynolds AJ. Child maltreatment and adult cigarette smoking: A long-term developmental model. Journal of Pediatric Psychology, 2010; 35(5):484-98. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19995869

52. Case A, Lubotsky D, and Paxson C. Economic status and health in childhood: The origins of the gradient. The American Economic Review, 2002; 92(5):1308–34. Available from: https://www.jstor.org/stable/3083252

53. Chen E, Martin AD, and Matthews KA. Socioeconomic status and health: Do gradients differ within childhood and adolescence? Social Science & Medicine, 2006; 62(9):2161–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16213644

54. Fagan P, Moolchan E, Lawrence D, Fernander A, and Ponder P. Identifying health disparities across the tobacco continuum. Addiction, 2007; 102(suppl. 2):5–29. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17850611

55. Harwood G, Salsberry P, Ferketich A, and Wewers M. Cigarette smoking, socioeconomic status, and psychosocial factors: Examining a conceptual framework. Public Health Nursing, 2007; 24(4):361–71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17553026

56. Giordano G and Lindstrom M. The impact of social capital on changes in smoking behaviour: A longitudinal cohort study. European Journal of Public Health, 2011; 21(3):34754. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20570962

57. Birch S. Commentary: Social inequalities in health, social epidemiology and social value. International Journal of Epidemiology, 2001; 30(2):294–6. Available from: http://ije.oxfordjournals.org/cgi/content/short/30/2/294

58. 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

59. Fergusson D, Horwood L, Boden J, and Jenkin G. Childhood social disadvantage and smoking in adulthood: Results of a 25-year longitudinal study. Addiction, 2007; 102(3):475–82. Available from: http://www3.interscience.wiley.com/journal/117967806/abstract


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

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

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