9.9 Are there inequalities in access to and use of treatment for dependence on tobacco-delivered nicotine?

 

Last updated: March 2022

Suggested citation:  Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.9 Are there inequalities in access to and use of treatment for smoking? In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-9-are-there-inequalities-in-access-to-and-usage-

 

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

 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 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 2018–19 as high SES smokers, and just as likely to have visited a website to obtain information about cessation or to have used a quitting app (see Figure 9.9.1).8

Figure 9.9.1  Use of Quitline, quitting app or website in last quit attempt, past year quit attempters, Victoria, 2018–19

Source: Centre for Behavioural Research in Cancer 20218

Similarly, data from Australia’s National Drug Strategy Household Survey in 2019 showed that disadvantaged past-year smokers were more likely to use the Quitline than the more advantaged (controlling for age and sex; see Figure 9.9.2).

Figure 9.9.2
Proportion of past year smokers who had contacted the Quitline, 2019

Source: Centre for Behavioural Research in Cancer analysis of AIHW National Drug Strategy Household Survey data, 2019.9

Further, although they may have lower success rates than higher SES smokers,10 quit rates among priority population callers to the Quitline suggest that the service is effective when used by high risk and underserved populations.11 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.12 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.)13

See Sections 7.14.1.4 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).14, 15 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,16 and to reduce the financial burden of smoking.17 However, there has traditionally been a lack of research into the effectiveness of such interventions among different social groups.18 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.16 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 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.19 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.20, 21 Mental health facilities and prisons—which are overrepresented by disadvantaged groups—also generally provide access to NRT.21 Bupropion (Zyban SR® and Prexaton ®) and varenicline (Champix®) 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 smokers with concession cards, with a substantially higher proportion of NRT prescription recipients being concessional. In 2020, 80% of all NRT prescriptions were for concession patients.  

Figure 9.9.3
Annual total number of prescriptions for anti-smoking medications, Australia, 2001 to 2020: bupropion, varenicline, and NRT

Source: Pharmaceutical Benefits Scheme database statistics  http://medicarestatistics.humanservices.gov.au/statistics/pbs_item.jsp

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.22 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.23 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.24 More recently, data from the 2019 National Drug Strategy Household Survey shows that disadvantaged smokers (first and second quintiles) were significantly more likely to use NRT and to use pharmacotherapies (controlling for age and sex; see Figure 9.9.4).25

 

Figure 9.9.4
Proportion of past year smokers who had used NRT and pharmacotherapy, 2019

Source: Centre for Behavioural Research in Cancer analysis of AIHW National Drug Strategy Household Survey data, 2019.9

Victorian data from 2018–19 similarly shows that low-SES smokers who had tried to quit in the past year were significantly more likely than mid-high-SES smokers to use varenicline or bupropion, and were just as likely to use NRT (see Figure 9.9.4).8

Figure 9.9.5 Use of NRT and cessation medications in last quit attempt, past year quit attempters (current smokers/recent quitters), Victoria, 2018–19

Source: Centre for Behavioural Research in Cancer, 20218

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 incomes.27, 28 The cost and time associated with visiting a doctor to obtain a prescription may outweigh the benefits of subsidies for some smokers.27 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 Aboriginal and Torres Strait Islander peoples29 and clients of social and community services,28 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.30, 31 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.32 Limited availability of cessation products in remote communities can also hinder use.33 US researchers found that very low-income smokers may also believe that cessation medications are dangerous.34 A review published in 2019 identified five key barriers related to abilities that prevent people in low socioeconomic groups from accessing cessation support:35

  • 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 smokers, compensating for their overall lower quit rates.36, 37 An Australian study found that offering subsidised NRT increased engagement with the Quitline among low-income smokers, which promoted successful quitting.38 The 2019 review noted above summarised five dimensions of cessation support that can help to address the barriers faced by low socioeconomic status smokers:35

  • 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 smokers are more likely to discontinue treatment early.39 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.32 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.40

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.41 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.39

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).23 More recently, data from the 2019 National Drug Strategy Household survey showed that among smokers who had tried to reduce their smoking or quit in the past year, low socioeconomic smokers (first and second quintiles) were just as likely as mid-high SES smokers to report that their doctor advising them to give up had motivated this change (see Figure 9.9.6).

Figure 9.9.6 Proportion of smokers who had tried to reduce their smoking or quit in the past year, who were motivated by doctor advice to quit, 2019

Source: Centre for Behavioural Research in Cancer analysis of AIHW National Drug Strategy Household Survey data, 2019.9

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.42 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.43 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.44 In the US however, research in 2019 found that patients attending a Federally Qualified Health Centers (who have higher smoking prevalence) were least likely to get referred to cessation services if they had more physical or mental health comorbidities, were in the lowest income group, were uninsured or were Hispanic.45

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.46

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 9A.3). 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 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.37, 43 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.37 Low SES smokers are more likely to receive a prescription for NRT than the more effective varenicline47 (see Figure 9.9.3), which may also partly explain their lower success rates in quitting.37

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 quitting37 (see Section 9.6).

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. 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.48 See Chapter 18 for a full discussion.

  

Relevant news and research

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

 

References 

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(suppl. 3):iii71–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16754950

3. Kotz D and West R. Explaining the social gradient in smoking cessation: It's not in the trying, but in the succeeding. Tobacco Control, 2009; 18(1):43–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18936053

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.

5. 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

6. 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

7. 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

8. 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.

9. Australian Institute of Health and Welfare. National Drug Strategy Household Survey, 2019. ADA Dataverse, 2021. Available from: http://dx.doi.org/10.26193/WRHDUL.

10. Varghese M, Sheffer C, Stitzer M, Landes R, Brackman SL, et al. Socioeconomic disparities in telephone-based treatment of tobacco dependence. American Journal of Public Health, 2014; 104(8):e76–84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24922165

11. Kerkvliet JL and Fahrenwald NL. Tobacco quitline outcomes for priority populations. South Dakota Medicine, 2015; Spec No:63–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25985612

12. Siahpush M, Wakefield M, Spittal M, and Durkin S. Antismoking television advertising and socioeconomic variations in calls to quitline. Journal of Epidemiology and Community Health, 2007; 61(4):298–301. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17372288

13. Dahne J, Wahlquist AE, Garrett-Mayer E, Heckman BW, Michael Cummings K, et al. The differential impact of state tobacco control policies on cessation treatment utilization across established tobacco disparities groups. Preventive Medicine, 2017; 105:319–25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28987337

14. Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, et al. Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: A review of reviews for the US preventive services task force. Annals of Internal Medicine, 2015; 163(8):608–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26389650

15. Stead LF, Koilpillai P, Fanshawe TR, and Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews, 2016; 3(3):CD008286. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27009521

16. 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

17. 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

18. 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

19. 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.

20. 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.

21. 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, 2016; 35(6):785–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26661119

22. Clare P, Slade T, Courtney RJ, Martire KA, and Mattick RP. 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; 16(12):1647–55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25320110

23. Partos T and Borland R. Data file of responses to eighth wave of the International Tobacco Control four-country survey, Provided to Merryn Pearce of the Tobacco Control Unit, 2012, Cancer Council Victoria.

24. Young-Wolff KC, Adams SR, Tan ASL, Adams AS, Klebaner D, et al. Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform. Preventive Medicine Reports, 2019; 14:100847. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31024786

25. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019. Drug Statistics series no. 32 Cat. no. PHE 270 Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/getmedia/3564474e-f7ad-461c-b918-7f8de03d1294/aihw-phe-270-NDSHS-2019.pdf.aspx?inline=true.

26. Tseng TS, Celestin MD, Jr., Yu Q, Li M, Luo T, et al. Use of geographic information system technology to evaluate health disparities in smoking cessation class accessibility for patients in Louisiana public hospitals. Front Public Health, 2021; 9:712635. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34476230

27. 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.proquest.com/scholarly-journals/views-low-socio-economic-smokers-what-will-help/docview/1115291181/se-2

28. 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: https://www.ncbi.nlm.nih.gov/pubmed/21699730

29. 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

30. Borland R, Pigott R, Rintoul D, Shore S, and Young S. Barriers to access of smoking cessation programs, nicotine replacement therapy and other pharmacotherapies for the general Australian population and at risk population groups. Literature review and volumes 1 and 2. Canberra: Final Report to Commonwealth Department of Health and Ageing, 2002.

31. Carter S, Borland R, and Chapman C. Finding the strength to kill your best friend–smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: https://www.researchgate.net/publication/329264979_Finding_the_strength_to_kill_your_best_friend_smokers_talk_about_smoking_and_quitting.

32. 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

33. 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

34. Christiansen B, Reeder K, Hill M, Baker TB, and Fiore MC. Barriers to effective tobacco-dependence treatment for the very poor. J Stud Alcohol Drugs, 2012; 73(6):874–84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23036204

35. van Wijk EC, Landais LL, and Harting J. Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review. Preventive Medicine, 2019; 123:143–51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30902700

36. Brown T, Platt S, and Amos A. Equity impact of population-level interventions and policies to reduce smoking in adults: A systematic review. Drug and Alcohol Dependence, 2014; 138:7–16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24674707

37. 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.

38. 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: https://www.ncbi.nlm.nih.gov/pubmed/19131454

39. 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

40. Burns E and Levinson A. Discontinuation of nicotine replacement therapy among smoking-cessation attempters. American Journal of Preventive Medicine, 2008; 34(3):212–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18312809

41. 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

42. 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

43. Smith CE, Hill SE, and Amos A. Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: A systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis. Addiction, 2020; 115(1):34–46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31357250

44. Edwards SA, Callaghan RC, Mann RE, and Bondy SJ. Association between socioeconomic status and access to care and quitting smoking with and without assistance. Nicotine & Tobacco Research, 2017; 20(1):40–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28340126

45. Liu J, Brighton E, Tam A, Godino J, Brouwer KC, et al. Understanding health disparities affecting utilization of tobacco treatment in low-income patients in an urban health center in southern California. Preventive Medicine Reports, 2021; 24:101541. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34976615

46. O'Brien J, Salmon AM, and Penman A. What has fairness got to do with it? Tackling tobacco among Australia's disadvantaged. Drug and Alcohol Review, 2012; 31(5):723–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22524309

47. 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

48. Lucherini M, Hill S, and Smith K. Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: A systematic review and synthesis of best available evidence. BMC Public Health, 2019; 19(1):1469. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31694602