Lower socio-economic status (SES) smokers tend to smoke more heavily, be more highly dependent on nicotine, and be less successful and confident in quitting. 1-4 For this reason they may benefit from extended and/or more intensive cessation interventions. It is therefore important that governments ensure such treatments and services are affordable, accessible, and attractive to disadvantaged smokers. Despite their lower success rates, low-SES smokers report being just as likely to prioritise and attempt quitting as high-SES smokers. 4, 5
Telephone-based cessation information and counselling services, such as the Quitline, offer enormous potential for the delivery of low cost and high reach cessation interventions (See Chapter 7, Section 7.14 ).Disadvantaged groups may face additional barriers to using the Quitline, such as lacking access to a phone, 6 and the cost of making the call from a mobile. 7 Nonetheless, recent Victorian data show that low SES smokers were just as likely to call the Quitline in 2015 as high SES smokers, and were more likely to have visited the Quit website to obtain information about cessation (see Figure 9.9.1). 4
Figure 9.9.1 Use of Quit website and Quitline in past 12 months among current smokers by SES, 2015
Source: Centre for Behavioural Research in Cancer 4
Similarly, data from the Australia’s National Drug Strategy Household Survey in 2016 showed that disadvantaged past-year smokers were more likely to use the Quitline than the more advantaged (see Figure 9.9.2). 5
Proportion of past year smokers who had contacted the Quitline, 2016
Source: Greenhalgh et al. 5 , using National Drug Strategy Household Survey data 2016 8
Further, although they may have lower success rates than higher SES smokers, 9 quit rates among priority population callers to the Quitline suggest that the service is effective when used by high risk and underserved populations. 10 In Australia, increased spending on (and therefore greater levels of public exposure to) antismoking campaigns appears to be as effective in prompting additional calls to the Quitline in lower, compared to higher, SES groups. 11 Research in the US that examined the impact of statewide tobacco control policies (such as tax increases, campaign funding, smokefree policies and free NRT to quitline callers) on the use of evidence-based tobacco dependence treatments also found that the policies were equally effective across socioeconomic groups in predicting use of quitlines. (Higher state tobacco taxes were more effective at increasing use by black Americans and smokefree policies and higher spending on media campaigns were more effective at increasing use by Hispanic smokers.) 12
See Sections 18.104.22.168 and 7.19.2 for an overview of the reach and effectiveness of Quitlines for low-income groups.
9.9.2 Disparities in use of treatments for tobacco dependence
The most effective form of cessation support is a combination of behavioural interventions (such as counselling) and pharmacotherapy (such as NRT or cessation medications). 13, 14 The development of targeted interventions that address smoking among low-SES groups is a high clinical and economic priority to reduce health inequalities and improve life expectancies, 15 and to reduce the financial burden of smoking. 16 However, there has traditionally been a lack of research into the effectiveness of such interventions among different social groups. 17 A systematic review of research over the past decade into cessation among low-SES and other disadvantaged groups concluded that the current research output is not ideal or optimal to decrease smoking rates. 15 Nonetheless, recent research has attempted to develop and tailor interventions to reduce smoking among low-income groups. See Chapter 7, Section 7.19 for an overview of cessation interventions for low-income, homeless, and other priority groups.
22.214.171.124 Disparities in use of treatments
Since February 2011, the Australian government has provided heavy subsidises of one 12-week course of nicotine patches per year with a prescription via the Pharmaceutical Benefits Scheme (PBS), with even greater subsidies for concession card holders. 18 Indigenous Australians can access additional courses of NRT at low or no cost under the Closing the Gap scheme and/or via community organisations. 19, 20 Mental health facilities and prisons—which are overrepresented by disadvantaged groups—also generally provide access to NRT. 20 Bupropion (Zyban SR® and Prexaton ®) and varenicline (Champix®) have been available on Australia’s PBS since 2001 and 2008, respectively.
Figure 9.9.3 shows the number of concessional and non-concessional prescriptions filled for cessation medications under the PBS since 2001. There was a substantial increase in uptake of NRT, bupropion, and varenicline, both among concessional and general patients, when each of these medications was added to the PBS. Since 2014, more prescriptions have been provided to smokers with concession cards, with a substantially higher proportion of NRT prescription recipients being concessional. In 2018, 78% of all NRT prescriptions were for concession patients.
Annual total number of prescriptions for anti-smoking medications, Australia, January 2001 to July 2019: bupropion, varenicline, and NRT
Other Australian data similarly shows high uptake of cessation medications among low-income groups. An analysis of data from the Australian National Drug Strategy Household Survey between 2001 and 2010 concluded that low-SES smokers use cessation support and services equally compared with high-SES smokers. Low-SES smokers were generally more likely to seek help from a doctor and to use prescription medication than high-SES smokers, which indicates their willingness to receive assistance with their quit attempts. 21 Data from wave eight (2010) of the International Tobacco Control Four-country Survey showed that those in the lowest income households were more likely than households of higher income to report using prescription stop-smoking medication. 22 More recently, data from the 2016 National Drug Strategy Household Survey shows that disadvantaged smokers were equally likely to use NRT, and more likely to use pharmacotherapies (see Figure 9.9.4). 5
Proportion of past year smokers who had used NRT and pharmacotherapy, 2016
Source: Greenhalgh et al. 5 , using National Drug Strategy Household Survey data 2016 8
Victorian data from 2015 similarly shows that low- and mid-SES smokers who had tried to quit in the past year tended to be more likely than high-SES smokers to use cessation aids or support (see Figure 9.9.4). In particular, more low-SES smokers had used cessation medications and internet sites than mid- and high-SES smokers.
Figure 9.9.5 Proportion of Victorian smokers using pharmacotherapy (NRT, cessation medications, or e-cigarettes), behavioural support (health professional advice, internet sites, self-help materials, quitline, or a mobile app), both, or any pharmacotherapy or behavioural service during their last quit attempt by SES, 2015
Source: Centre for Behavioural Research in Cancer, 2016 4
Despite these encouraging findings, disadvantaged groups may still face barriers to accessing and using cessation medications. Even with subsidisation, the cost of pharmacotherapies may hinder their use among those on low incomes. 23, 24 The cost and time associated with visiting a doctor to obtain a prescription may outweigh the benefits of subsidies for some smokers. 23 Recent Victorian research found that low-SES smokers were equally as likely as higher-SES smokers to be aware that NRT is available on the PBS; 4 however some groups, such as Indigenous Australians 25 and clients of social and community services, 24 may lack such awareness. Australian smokers may underrate the potential usefulness of cessation interventions and pharmacotherapies, and this is particularly true for smokers in low-income groups. 26, 27 A qualitative study with Indigenous Australians found that some participants were skeptical and distrustful of pharmaceutical support for quitting, perceiving it as addictive and its use as evidence of poor willpower. 28 Limited availability of cessation products in remote communities can also hinder use. 29 US researchers found that very low-income smokers may also believe that cessation medications are dangerous. 30
Targeted national smoking cessation services appear to reduce inequalities in smoking prevalence by achieving higher reach among disadvantaged smokers, compensating for their overall lower quit rates. 31, 32 An Australian study found that offering subsidised NRT increased engagement with the Quitline among low-income smokers, which promoted successful quitting. 33
126.96.36.199 Disparities in compliance with treatment
Adherence to pharmacotherapy (i.e., taking it as directed) increases the chances of cessation, however low-SES smokers are more likely to discontinue treatment early. 34 A small Australian study found that among Indigenous Australians who had used cessation aids, none had completed the full course of treatment. 28 A study of smokers using NRT in the general US community (i.e. NRT purchased over the counter rather than prescribed by their doctor) found that those with very low incomes and those of minority status were much more likely to discontinue NRT use if they had slipped up, if they suffered side effects, or if they felt that it was not helping with quitting. 35
Similarly a study of smokers using cessation services in the UK (which included group program and one-to-one behavioural support, as well as the offer of pharmacotherapy) reported that at 52-week follow up, 14% of smokers of higher-SES had remained quit, compared to about 5% of smokers in the lowest socio-economic group. The researchers concluded treatment compliance was one of the factors relating to disparity in quitting success. 36 Tobacco control interventions that increase support for quit attempts, enhance motivation and self-efficacy, and reduce other life stress may help to increase treatment compliance among low-SES groups. 34
9.9.3 Disparities in provision of quit smoking advice and referral by general practitioners
Data from the seventh wave of the International Tobacco Control Four-country Survey (between October 2008 and March 2009) showed that smokers of lower educational attainment were more likely than any other group to report being advised to quit smoking by their doctor. There was a slight increase from 2006 among smokers who had completed schooling, obtained a trade qualification or completed some university reporting being advised to quit (up from 51%, 52% and 48% respectively).
Figure 9.9.6 Proportion of smokers who could recall having been advised to quit by their doctor, Australia, 2008–09, by level of educational attainment
Source: Data file of responses to seventh wave of the International Tobacco Control Four-country Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, Cancer Council Victoria, 2012
Research in England similarly found that in 2014–16, the delivery of brief interventions for smoking by primary healthcare professionals was highest in lower socioeconomic groups. 37 A review of cessation support in the UK found that primary care providers and stop smoking services were particularly effective at engaging and supporting disadvantaged smokers. Low SES groups were more likely to have their smoking status assessed, to receive general practitioner brief cessation advice/referral and to attempt a quit with support. 38 Findings from a study in Canada showed that smokers who recently visited a doctor were more likely to report quitting with assistance than without, and those also advised to quit by their doctor were even more likely to quit with assistance, regardless of SES. 39
In Australia, the ‘Tackling Tobacco’ initiative undertaken by the Cancer Council NSW aims to encourage and support non-government social and community services to address smoking among their clients. An evaluation of program results ‘challenged assumptions and attitudes that disadvantaged people are uninterested or unable to quit’. Clients of these organisations were receptive to receiving quitting support from the trained staff in these services, and the staff providing this care report knowledge and confidence in addressing tobacco among their clients. The program results also indicate improvement in quality of life among clients who do quit smoking. 40
Nonetheless, there are some settings where disadvantaged smokers may be less likely to receive advice and support to quit. Smoking has traditionally been supported and encouraged in mental health and drug and alcohol settings (see Section 7.12). The normalisation of smoking among Indigenous communities, along with the high prevalence among healthcare workers, can similarly hinder the provision of cessation support (see Chapter 8). Further, while low SES smokers are generally more likely to have their smoking status assessed and to be offered cessation support, they are less likely to successfully quit smoking as a result of this support. These lower success rates can be offset by targeting and achieving higher reach in low SES communities. 32, 38 For example, in 2011 Scotland introduced a national equity-based target in its stop smoking services, which has led to relatively more low SES smokers quitting. 32 Low SES smokers are more likely to receive a prescription for NRT than the more effective varenicline 41 (see Figure 9.9.3), which may also partly explain their lower success rates in quitting. 32
Overall, encouraging and integrating tobacco cessation with disadvantaged populations and settings, and setting equity targets, may form an important part of reducing the disparities in smoking and health. Innovative interventions, such as financial incentives, tailored advice matched to literacy levels, and mobile or outreach services, also have the potential to increase the success rates of low SES smokers quitting 32 (see Section 17.9.2).
9.9.4 Harm reduction: a strategy of benefit for disadvantaged groups?
Disadvantaged smokers tend to smoke more heavily, be more highly dependent on nicotine, and be less successful at quitting. 2, 3 For smokers who are unwilling or unable to quit, harm reduction—through regulatory approaches such as reducing the harmfulness of cigarettes or individual approaches such as switching to alternative products that may carry fewer risks than traditional cigarettes—has been suggested as an alternative to complete cessation. See chapter 18 for a full discussion.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated July 2019)
1. Hyland A, Borland R, Li Q, Yong HH, McNeill A, et al. Individual-level predictors of cessation behaviours among participants in the international tobacco control (ITC) four country survey. Tobacco Control, 2006; 15 Suppl 3:iii83-94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16754952
2. Siahpush M, McNeill A, Borland R, and Fong GT. Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the international tobacco control (ITC) four country survey. Tobacco Control, 2006; 15(suppl. 3):iii71–iii5. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii71
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4. Centre for Behavioural Research in Cancer. Quitting strategies used by current smokers and recent quitters: Findings from the 2015 Victorian smoking and health survey. Melbourne: Cancer Council Victoria, 2016.
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8. Australian Institute for Health and Welfare, National Drug Strategy Household Survey, 2016 [computer file]. Canberra: Australian Data Archive, The Australian National University; 2017.
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14. Stead LF, Koilpillai P, Fanshawe TR, and Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews, 2016; (3). Available from: http://dx.doi.org/10.1002/14651858.CD008286.pub3
15. 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: http://www.ncbi.nlm.nih.gov/pubmed/26062037
16. 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: http://www.ncbi.nlm.nih.gov/pubmed/26021316
17. Ogilvie D and Petticrew M. Reducing social inequalities in smoking: Can evidence inform policy? A pilot study. Tobacco Control, 2004; 13(2):129–31. Available from: http://tc.bmjjournals.com/cgi/content/abstract/13/2/129
18. Australian Government, The extension of the listing of nicotine patches on the pharmaceutical benefits scheme from 1 February 2011. Department of Health; 2013. Available from: http://www.pbs.gov.au/info/publication/factsheets/shared/Extension_of_the_listing_of_nicotine_patches.
19. Ivers R, Anti-tobacco programs for Aboriginal and Torres Strait Islander people. Produced for the closing the gap clearinghouse. Canberra: Australian Institute of Health and Welfare & Melbourne: Australian Institute of Family Studies; 2011. Available from: http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2011/ctgc-rs04.pdf.
20. Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, et al. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug and Alcohol Review, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26661119
21. Clare P, Slade T, Courtney RJ, Martire KA, and Mattick RP. The use of smoking cessation and quit support services by socioeconomic status over 10 years of the National Drug Strategy Household Survey. Nicotine & Tobacco Research, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25320110
22. Partos T and Borland R. Data file of responses to eighth wave of the international tobacco control four-country survey, in Provided to Merryn Pearce of the Tobacco Control Unit2012, Cancer Council Victoria.
23. Glover M, Fraser T, and Nosa V. Views of low socio-economic smokers: What will help them to quit? Journal of Smoking Cessation, 2012; 7(1):41–6. Available from: https://www.cambridge.org/core/article/views-of-low-socio-economic-smokers-what-will-help-m-to-quit/A24E4B2FC2F9078B510D5545E7F14700
24. Bryant J, Bonevski B, Paul C, O'Brien J, and Oakes W. Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers. BMC Public Health, 2011; 11:493. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21699730
25. Gould GS, Munn J, Watters T, McEwen A, and Clough AR. Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and torres strait islanders: A systematic review and meta-ethnography. Nicotine & Tobacco Research, 2013; 15(5):863–74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23042985
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28. Bond C, Brough M, Spurling G, and Hayman N. ‘It had to be my choice’ Indigenous smoking cessation and negotiations of risk, resistance and resilience. Health, Risk & Society, 2012; 14(6):565–81. Available from: http://dx.doi.org/10.1080/13698575.2012.701274
29. Johnston V and Thomas DP. What works in Indigenous tobacco control? The perceptions of remote Indigenous community members and health staff. Health Promotion Journal of Australia, 2010; 21(1):45–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20406152
30. Christiansen B, Reeder K, Hill M, Baker T, and Fiore M. Barriers to effective tobacco-dependence treatment for the very poor. Journal of Studies on Alcohol and Drugs, 2012; 73(6):874–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23036204
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32. 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.
33. Miller CL and Sedivy V. Using a quitline plus low-cost nicotine replacement therapy to help disadvantaged smokers to quit. Tobacco Control, 2009; 18(2):144–9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/2/144
34. 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
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36. Hiscock R, Judge K, and Bauld L. Social inequalities in quitting smoking: What factors mediate the relationship between socioeconomic position and smoking cessation? Journal of Public Health, 2010; 33(1):39–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21178184
37. Angus C, Brown J, Beard E, Gillespie D, Buykx P, et al. Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: Findings from a cross-sectional household survey in England. BMJ Open, 2019; 9(4):e023448. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31048422
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41. Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (eagles): A double-blind, randomised, placebo-controlled clinical trial. The Lancet, 2016; 387(10037):2507–20. Available from: https://doi.org/10.1016/S0140-6736(16)30272-0