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Last updated: November 2022

9.7 Explanations of socio-economic disparities in smoking

'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 2003 1 p807

Low socioeconomic status (SES) groups have substantially higher smoking rates than the overall population, both in Australia and internationally (see Section 9.1). Higher smoking rates among low-SES groups are associated with a web of interacting physiological, psychological, social, economic, commercial, and cultural factors, 2 including:

  • nicotine exposure in utero and during childhood 3-6
  • parental and peer relationships and modelling 7-16
  • lower achievement and satisfaction at school 16-18 and lower educational attainment in adulthood 19-21
  • stress, 22 , 23 mental illness, 24-29 and substance use/dependence 30
  • a greater likelihood of belonging to a priority population among whom smoking is more common, such as Aboriginal and Torres Strait Islander peoples, people experiencing incarceration, or LGBTQI+ people
  • social isolation 31
  • for minority groups, experiencing discrimination. 32-34
  • a lesser tendency to consider and value future outcomes 35-38
  • the endorsement of beliefs that minimise or discount the risks of smoking 39
  • workplaces 40 and social circles 41 that normalise smoking
  • job loss 42 and financial stress 43
  • a lower likelihood of working indoors 44-46
  • living in a disadvantaged neighbourhood 47-50 or low-income housing 51
  • representations of smoking in popular culture 52-55
  • a history of targeted and intensive marketing 56-60
  • less success in maintaining cessation, despite being just as likely to make a quit attempt and to use cessation aids (see Section 9.8)

The above factors vary in importance in explaining socio-economic disparities at different developmental stages 61 and at different stages in the tobacco addiction cycle. 1 , 61 As with other aspects of social disadvantage, many factors driving tobacco-related disparities originate in childhood 62-67 and accumulate throughout the individual’s life. 64 , 68-70 It is also important to consider heterogeneity within groups, and that possessing multiple attributes that are associated with high smoking prevalence (for example, belonging to a priority group and having a lower education level) may interact and further increase a person’s risk of smoking. 71 , 72

While a wealth of information is available on associations between social disadvantage and tobacco use, 73-75 understanding the causal mechanisms underlying these associations is more challenging. 76 Nonetheless, recent studies suggest that some of these factors can causally impact a person’s risk of smoking. For example, a large study in the UK found that more years of education leads to reduced likelihood of smoking uptake, and reduced heaviness of smoking and greater likelihood of quitting among smokers. 19 Another UK study suggests that the relationship between disadvantage and smoking uptake can largely be explained by parental modelling of smoking. That is, reducing disadvantaged children’s exposure to smoking may largely reduce future disparities in tobacco use. 77

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.
Points in yellow indicate factors known or likely to drive disparities.

See InDepth 9A for a detailed discussion of smoking prevalence, the role of smoking in health and social inequalities, and cessation interventions tailored and targeted for: people living in regional and remote areas of Australia; culturally and linguistically diverse groups; people with substance use and mental disorders; people experiencing homelessness; people experiencing incarceration; lesbian, gay, bisexual, trans, queer and intersex (LGBTQI+) people; military personnel and veterans; and single parents

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated June 2024)

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Intro
Chapter 2