More recent Victorian data 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.
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.14, 15 The cost and time associated with visiting a doctor to obtain a prescription may outweigh the benefits of subsidies for such smokers.14 Recent Victorian research found that low-SES smokers were equally likely to be aware that NRT is available on the PBS;4 however some groups, such as Indigenous Australians16 and clients of social and community services,15 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.17, 18 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.19 Limited availability of cessation products in remote communities can also hinder use.20 US researchers found that very low-income smokers may also believe that cessation medications are dangerous.21
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.22 An Australian study found that offering subsidised NRT increased engagement with the Quitline among low-income smokers, which promoted successful quitting.23
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.24 A small Australian study found that among Indigenous Australians who had used cessation aids, none had completed the full course of treatment.19 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.25
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.26 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.24
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).
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
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 ). Encouraging and integrating tobacco cessation with such populations and settings may form an important part of reducing the disparities in smoking and health.
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.(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
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: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/1/43
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. 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). Available from: http://www.ncbi.nlm.nih.gov/pubmed/26703662
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9. Siahpush M, Wakefield M, Spittal M, and Durkin S. Anti-smoking television advertising and socio-economic variations in calls to quitline. Journal of Epidemiology and Community Health, 2007; 61(4):298–301. Available from: http://jech.bmj.com/cgi/content/full/61/4/298
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
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18. 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: http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf
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22. 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: http://www.ncbi.nlm.nih.gov/pubmed/24674707
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