People who smoke who live in lower socio-economic status (SES) areas 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 people who smoke. Despite their lower success rates, low-SES people who smoke report being just as likely to prioritise and attempt quitting as those living in more advantaged areas.4,5
9.9.1 Quitlines
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 telephone or internet cessation services, such as lacking access to high-speed internet,6 not owning a phone,7 and the cost of making the call from a mobile.8 Nonetheless, data from Australia’s National Drug Strategy Household Survey in 2022–2023 showed that low SES people who had smoked in the past year were just as likely to use the Quitline, to have visited a website to obtain information about quitting, or to have used a quitting app as those who were high SES (controlling for age and sex)9—see Figure 9.9.1. Earlier Victorian data showed the same pattern of findings.10
Although they may have lower success rates than higher SES people who smoke,11 quit rates among lower SES and priority population callers to the Quitline suggest that the service is effective when used by high risk and underserved populations.12 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.13 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 people who smoke.14
See Sections 7.14.1.3 and 9.6 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).15,16 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,17 and to reduce the financial burden of smoking.18 However, there has traditionally been a lack of research into the effectiveness of such interventions among different social groups.19 A systematic review of research over the past decade concluded that the current research output is not ideal or optimal to determine the most effective strategies to decrease smoking rates among low-SES and other disadvantaged groups.17 Nonetheless, recent research has attempted to develop and tailor interventions to reduce smoking among low-income groups. See Section 9.6 for an overview of targeted interventions for low socioeconomic groups and InDepth 9A on addressing smoking in highly disadvantaged and other priority groups.
9.9.2.1 Disparities in use of treatments
Since February 2011, the Australian government has provided subsidises for nicotine patches to people who smoke with a prescription via the Pharmaceutical Benefits Scheme (PBS), with even greater subsidies for concession card holders.20 Aboriginal and Torres Strait Islander peoples can access additional courses of NRT at low or no cost under the Closing the Gap scheme and/or via community organisations.21,22 Mental health facilities and prisons—where disadvantaged groups are overrepresented—also generally provide access to NRT.22 Bupropion and varenicline have been available on Australia’s PBS since 2001 and 2008, respectively.
Figure 9.9.2 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 people with concession cards who smoke, with a substantially higher proportion of NRT prescription recipients being concessional. The sharp drop in varenicline prescriptions in 2021 reflects a pause in global distribution of Champix after product impurities were identified—see Section 7.16. In 2023, 77% of all NRT prescriptions were for concession patients.
Other Australian data shows similar use of cessation medications among low-income and high-income groups. An analysis of data from the Australian National Drug Strategy Household Survey between 2001 and 2010 concluded that low-SES people who smoke use cessation support and services equally compared with those who are high-SES. Those who were low-SES were generally more likely to seek help from a doctor and to use prescription medication than high-SES people who smoke, which indicates their willingness to receive assistance with their quit attempts.23 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.24 Research in the US found that following the implementation of the Affordable Care Act in 2014, there were no differences in receiving clinician advice to quit and knowledge and use of tobacco treatment by sociodemographics, insurance type, comorbidities, or smoking status.25 More recently, data from the 2022–2023 National Drug Strategy Household Survey shows that there were no differences in past year use of pharmacotherapies or NRT by socioeconomic status (controlling for age and sex; see Figure 9.9.3).9
Victorian data from 2018–19 similarly shows that low-SES people who smoke who had tried to quit in the past year were significantly more likely than those who were mid-high-SES to use varenicline or bupropion, and were just as likely to use NRT (see Figure 9.9.4).10
Despite these encouraging findings, disadvantaged groups may still face barriers to accessing and using cessation medications. Greater distances from treatment providers can reduce the accessibility of cessation support for vulnerable groups.26 Even with subsidisation, the cost of pharmacotherapies may hinder their use among those on low incomes27,28 and among Aboriginal and Torres Strait Islander peoples.29 The cost and time associated with visiting a doctor to obtain a prescription may outweigh the benefits of subsidies.27 Victorian research found that low-SES people who smoke were equally as likely as higher-SES people to be aware that NRT is available on the PBS;4 however some groups, such as Aboriginal and Torres Strait Islander peoples30 and clients of social and community services,28 may lack such awareness. Further, research with Aboriginal and Torres Strait Islander peoples has found that inhalers are one of the preferred types of NRT, and these are not subsidised on the PBS.29 Australians who smoke may underrate the potential usefulness of cessation interventions and pharmacotherapies, and this is particularly true for those in low-income groups.31,32 A qualitative study with Aboriginal and Torres Strait Islander peoples 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.33 Limited availability of cessation products in remote communities can also hinder use.34 US researchers found that very low-income people who smoke may also believe that cessation medications are dangerous.35 A review published in 2019 identified five barriers related to abilities that prevent people in low socioeconomic groups from accessing cessation support:36
- Ability to perceive: lack of perceptions of the need for support, the need/motivation to quit, and the health risks of smoking
- Ability to seek: lack of knowledge and distrust and misperceptions about cessation support, as well as low self-efficacy
- Ability to reach: living in areas with few resources, and lacking social support and mobility
- Ability to pay: particularly in countries where cessation support is not subsidised/free
- Ability to engage: discouragement and low self-efficacy from repeated experiences of relapse, due to high levels of dependence, stressful living conditions, poor social support, social norms, and weight gain.
Targeted national smoking cessation services appear to reduce inequalities in smoking prevalence by achieving higher reach among disadvantaged people who smoke, compensating for their overall lower quit rates.37,38 An Australian study found that offering subsidised NRT increased engagement with the Quitline among low-income people who smoke, which promoted successful quitting.39 An initiative in NSW, Victoria and the ACT that involved mailing combination NRT products to Aboriginal and Torres Strait Islander peoples wanting to quit alongside culturally tailored behavioural support found that it was acceptable, feasible, and increased quitting success.40,41 The 2019 review noted above summarised five dimensions of cessation support that can help to address the barriers faced by low socioeconomic status people:36
- Approachability: the use of personal and proactive strategies by health professionals
- Acceptability: being trained in and providing evidence-based support, and prioritising cessation interventions
- Availability and accommodation: the availability of local, flexible (e.g., drop-in), and comprehensive (both pharmacotherapy and behavioural counselling) cessation support
- Affordability: full reimbursements for all forms of first-line cessation support, so that interventions can be tailored
- Appropriateness: offering flexible, intensive, targeted support, and also addressing material and social circumstances that maintain smoking.
9.9.2.2 Disparities in compliance with treatment
Adherence to pharmacotherapy (i.e., taking it as directed) increases the chances of cessation, however low-SES people who smoke are more likely to discontinue treatment early.42 A small Australian study found that among Aboriginal and Torres Strait Islander peoples who had used cessation aids, none had completed the full course of treatment.33 A study of people who smoke 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.43
Similarly a study of people who smoke 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 those of higher-SES had remained quit, compared to about 5% of people who smoke in the lowest socio-economic group. The researchers concluded treatment compliance was one of the factors relating to disparity in quitting success.44 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.42
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 people who smoke 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 people who smoke who had completed schooling, obtained a trade qualification or completed some university reporting being advised to quit (up from 51%, 52% and 48% respectively).24 More recently, data from the 2022–2023 National Drug Strategy Household survey showed that among people who had tried to reduce their smoking or quit in the past year, those in low socioeconomic areas were just as likely as those in mid-high SES areas to report that their doctor advising them to give up had motivated this change (see Figure 9.9.5).
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.45 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 people who smoke. 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.46 Research in the US similarly found that people with lower incomes or education levels or equally or more likely to receive advice and support to quit.47,48 Findings from a study in Canada showed that people who smoke 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.49
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.50
Nonetheless, there are some settings where disadvantaged people who smoke may be less likely to receive advice and support to quit. Addressing smoking may be deprioritised if health professionals feel there are more pressing concerns for patients.51 Smoking has traditionally been supported and encouraged in mental health and drug and alcohol settings due to misperceptions that quitting may exacerbate mental health symptoms (see Section 9.6). The normalisation of smoking among Aboriginal and Torres Strait Islander communities, along with the high prevalence among healthcare workers, can similarly hinder the provision of cessation support (see Chapter 8). Further, while low SES people 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.38,46 For example, in 2011 Scotland introduced a national equity-based target in its stop smoking services, which has led to relatively more low SES people quitting.38 Low SES people who smoke are more likely to receive a prescription for NRT than the more effective varenicline52 (see Figure 9.9.2), which may also partly explain their lower success rates in quitting.38
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 people quitting38 (see Section 9.6).
9.9.4 Harm reduction: a strategy of benefit for disadvantaged groups?
Disadvantaged people who smoke tend to smoke more heavily, be more highly dependent on nicotine, and be less successful at quitting.2,3 For those 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. A review of the potential equity impact of non-combustible nicotine products (smokeless tobacco, e-cigarettes, and NRT) found that only smokeless tobacco use was higher among low-SES groups, but did not appear to displace use of combustible tobacco, and there was no evidence that e-cigarettes have the potential to reduce disparities in smoking.53 See Chapter 18 for a full discussion.
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References
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