Socioeconomic status and smoking: a review

Ann. N.Y. Acad. Sci. ISSN 0077-8923

ANNALS OF THE NEW YORK ACADEMY OF SCIENCESIssue: Addiction Reviews

Socioeconomic status and smoking: a review

Rosemary Hiscock,1,6 Linda Bauld,2,6 Amanda Amos,3,6 Jennifer A. Fidler,4,6

and Marcus Munafo5,6

1Tobacco Control Research Group, Department of Health, University of Bath, Bath, United Kingdom. 2Stirling ManagementSchool, University of Stirling, Stirling, United Kingdom. 3Centre for Population Health Sciences, University of Edinburgh,Edinburgh, United Kingdom. 4Health Behaviour Research Centre, Department of Epidemiology and Public Health, UniversityCollege London, London, United Kingdom. 5School of Experimental Psychology, University of Bristol, Bristol, United Kingdom.6United Kingdom Centre for Tobacco Control Studies (UKCTCS), United Kingdom

Address for correspondence: Rosemary Hiscock, Tobacco Control Research Group, Department of Health, University of Bath,Bath, UK, BA2 7AY. [email protected]

Smoking prevalence is higher among disadvantaged groups, and disadvantaged smokers may face higher exposureto tobacco’s harms. Uptake may also be higher among those with low socioeconomic status (SES), and quit attemptsare less likely to be successful. Studies have suggested that this may be the result of reduced social support forquitting, low motivation to quit, stronger addiction to tobacco, increased likelihood of not completing courses ofpharmacotherapy or behavioral support sessions, psychological differences such as lack of self-efficacy, and tobaccoindustry marketing. Evidence of interventions that work among lower socioeconomic groups is sparse. Raising theprice of tobacco products appears to be the tobacco control intervention with the most potential to reduce healthinequalities from tobacco. Targeted cessation programs and mass media interventions can also contribute to reducinginequalities. To tackle the high prevalence of smoking among disadvantaged groups, a combination of tobacco controlmeasures is required, and these should be delivered in conjunction with wider attempts to address inequalities inhealth.

Keywords: socioeconomic status; health inequalities; disparities; smoking; tobacco control

Introduction

Socioeconomic status (SES) refers to the positionthat a person occupies in the structure of society dueto social or economic factors.1 Incidence of disease,disability, and premature death is higher for lowersocioeconomic groups—two or three times higherin the EU, for example.2 Disadvantaged groups glob-ally, aged between 35 and 69, are much more likelyto die from smoking.3 Tobacco is responsible forabout half the SES difference in death rates for thisage range.4 Furthermore, smoking can be a strongerpredictor of long-term survival than SES.5 World-wide, there are 5.4 million smoking-related deathsper year.6 Smoking cessation improves lung func-tion and reduces the risk of coronary heart disease,cancer, and stroke.7

Internationally, smoking rates are particularlyhigh among the long-term unemployed, homeless,

mentally ill, prisoners, single parents, and somegroups of new immigrants and ethnic minori-ties2,8—all of whom are more likely to be socioeco-nomically disadvantaged. In this article, we reviewresearch on this underlying driver of smoking rates:socioeconomic inequalities in smoking, rather thanthe particular needs of each subpopulation, as re-search on smoking and smoking cessation in someof these groups is relatively sparse.8 We do recognizethe importance of ethnic differences. However, someethnic minorities tend to smoke less than the ma-jority and others more.9 Furthermore, each countryhas a unique profile of ethnic minorities includingnative and immigrant groups. Thus, an understand-ing of ethnic issues may be better served by a focuson one country or region.

What this review does include is a discussionof SES differences in smoking prevalence and con-sumption (including exposure to tobacco) and then

doi: 10.1111/j.1749-6632.2011.06202.xAnn. N.Y. Acad. Sci. 1248 (2012) 107–123 c© 2012 New York Academy of Sciences. 107

Socioeconomic status and smoking: a review Hiscock et al.

how these differences have been produced throughdifferences in uptake and cessation. This includesthe low rates of cessation among disadvantagedpregnant women—a group that would, perhaps, beexpected to have high quit rates, given their lackof income and a desire to protect their unbornchildren. Many of the general patterns of smokingprevalence by SES are familiar, so we also presentevidence on the underlying mechanisms that makequitting difficult for those with low SES. Finally,we outline which tobacco control interventions arelikely to disproportionately reduce smoking in dis-advantaged groups and thus reduce inequalities insmoking rates.

The topic of SES and smoking is vast; we there-fore used a variety of methods to review relevantdata and study findings. All authors are members ofthe UK Centre for Tobacco Control Studies and thuswere able to draw on a network of expertise in theUnited Kingdom and beyond. We particularly makeuse of recent reviews of disadvantage and smok-ing,2,3,8–12 and also refer to evidence from the Smok-ing Toolkit Study, a large, repeated cross-sectionalsurvey of the English population with postal follow-ups, which was designed specifically to examine themechanisms underlying patterns in smoking cessa-tion.13–19 A rapid review of the PubMed databasefrom 2005 to the present was also conducted(Table 1). For the mechanisms underlying SES dif-ferences in smoking, we augmented this by con-ducting a more purposive search chiefly throughGoogle Scholar. In order to explore smoking preva-lence and cigarette consumption, we mainly usedinternational comparisons to gauge the ubiquityof the relationship between SES and smoking,unless a single country study raised an issueof interest or increased the breadth of previouscomparisons.

SES and smoking prevalence

Smoking rates are higher among those with lowerSES in the majority of developed countries,20–22

although in some regions, such as southern Eu-rope, inequalities are only just beginning to emergeamong women.2,23 In the United States, for exam-ple, less than 20% of those at or above the povertylevel smoke, but more than 30% of those belowthe poverty level smoke.24 Socioeconomic differ-ences in smoking prevalence have also been foundwhen examining factors such as education, income,

Table 1. Rapid review of PubMed database

Search termsSES inequalit∗ [title] or SES [title] or

socioeconomic [title] or

depriv∗ [title] or disadvant∗

[title] or social class∗ [title] or

unemploy∗ [title] or educat∗

[title] or income [title] or

poverty [title] or neighbor∗

[title] or geograp∗ [title]

Smoking quit∗[title/abstract]) or

cessation[title/abstract]

Limits English language, 2005 to

7/20/2011

ResultsTotal found 320

Total after title search 72

Total after abstract search 28

and receipt of Medicaid.10 In England, 25% ofthose whose current or most recent occupation is“manual” smoke, compared with 16% of nonman-ual groups.25 Other socioeconomic measures wheresmoking prevalence differences are significant inEngland include income, housing tenure, car avail-ability, economic status, lone parenting, and neigh-borhood deprivation.12 Smoking rates are highestin the most disadvantaged neighborhoods in termsof worklessness, vandalism, and community cohe-sion.26 A Finnish study found that smoking was re-lated to structural, material, and perceived aspectsof SES.27 There is also a cumulative effect of dis-advantage: for example, one study found the high-est smoking prevalence in localities characterizedby single-parent households living in public rentedaccommodation, with little community support,residents who have no access to a car with few oc-cupational qualifications and high TV-viewing be-havior.28 Smoking rates among those experiencingmany forms of disadvantage in developed countriescan be above 60%, which is four times higher thanamong the most affluent.12,28,29

Elsewhere, in countries such as Brazil, China,South Africa, Vietnam, India, and Central Amer-ica, the smoking rates by the mid-1990s were lowerin men with more education.30 However, it is notthe case that the gradient is consistent or even

108 Ann. N.Y. Acad. Sci. 1248 (2012) 107–123 c© 2012 New York Academy of Sciences.

Hiscock et al. Socioeconomic status and smoking: a review

showing the same direction in all countries. Anal-ysis of the World Health Survey in 2003 suggestedthat higher smoking prevalence among the high-est income quintile compared to the lowest incomequintile was more marked in the lowest incomecountries than in the upper-middle–income coun-tries.3 Analysis of education in the same survey,however, suggested more disparity in smoking ratesin middle- compared to lower-income countries, es-pecially among men and among both sexes underage 40.31 The authors of this study also concludedthat inequalities were likely to grow in the future astobacco use becomes more widely diffused and low-income countries come to resemble middle-incomecountries. Although there is evidence of a socioe-conomic gradient in smoking in most lower- andmiddle-income countries, there are still ambigui-ties. Some of these differences have been explainedby the tobacco epidemic four-stage model, whichdescribes the nature of tobacco use development: inthe first stage, tobacco use commences among menonly; in the second stage, smoking grows rapidlyamong men and begins in earnest among women;in the third stage, smoking begins to decline, partic-ularly among men; and in the fourth stage, smokingcontinues to decline slowly, but SES differences be-come apparent.32 From the data now available, itcould be argued that there are noticeable SES dis-parities in some countries before the fourth stage.

Overall, therefore, there is evidence that lowSES is generally but not ubiquitously associatedwith smoking in poor, intermediate, and rich na-tions. Studies from high-income countries are morenumerous.

SES and tobacco consumptionWithin developed countries, heavy smoking is morecommon among people of high SES than lowSES.12,30 For other countries, where data are avail-able, poorer smokers smoke more or equal numbersof cigarettes per day (an exception is India, wherepoorer people tend to smoke bidis).3,30 Measures oflight or heavy smoking, however, may not be thebest indictors of tobacco exposure.

SES and exposure to tobacco. It is now well-established that smokers modify their smoking be-havior to self-titrate, circulating nicotine to a levelappropriate to their need.33 This compensatory be-havior is achieved through varying the number ofpuffs, puff volume, and interpuff interval, as well

as covering the cigarette filter to reduce ventila-tion by side-stream air. This plasticity of smok-ing behavior has resulted in growing consensusthat estimating exposure to nicotine and tar incigarette smokers is not possible through the use ofmachine-protocols to calculate yield estimates34 orthrough simple counting of number and strengthof cigarettes smoked. Smokers are able to titratenot only how many cigarettes they smoke, but alsowhat strength of cigarette they smoke, and how theysmoke them.

This, combined with misreporting of smokingbehavior—for example, by smokers reporting thatthey smoke fewer cigarettes than they in fact do—will reduce the reliability of self-report measures asan index of tobacco exposure. Either biochemicalmeasures of exposure or naturalistic measures ofsmoking topography are necessary if an acceptablelevel of measurement precision is to be achieved.35

This is supported by evidence that cotinine con-centrations, the primary metabolite of nicotine, aremore strongly associated with a genetic risk factorfor heavy smoking than self-reported daily cigaretteconsumption (Munafo, personal communication).

Objective measures of tobacco use, such as co-tinine concentrations, may give us greater insightinto the social patterning of tobacco use and expo-sure. Objective measures of exposure can be usedin two broad ways. One is to reclassify those whoreport themselves to be nonsmokers as smokers, onthe basis of a concentration too high to be achiev-able through exposure to environmental tobaccosmoke, for example. The other is to assess more ac-curately actual levels of exposure within smokers,given interindividual differences in cigarette brandpreference (which may vary by tar and nicotine con-tent), smoking topography, and so on. For example,there is evidence that misreporting of smoking sta-tus in pregnant women differs by socioeconomicposition, with those from less-deprived areas morelikely not to report their smoking compared withwomen from more-deprived areas.36 In addition,there is also evidence that tobacco exposure differsby socioeconomic position—those in positions ofgreater economic deprivation show higher levels ofcotinine concentration than those in more affluentpositions, even when daily cigarette consumption isadjusted for.18

This suggests that cigarette smoking hits the eco-nomically disadvantaged doubly hard—they are not

Ann. N.Y. Acad. Sci. 1248 (2012) 107–123 c© 2012 New York Academy of Sciences. 109


only more likely to smoke and, if they do, to smokemore cigarettes per day, but also appear to smokeeach cigarette more heavily and therefore extractmore nicotine (and therefore tar) per cigarette. It isclear that self-report measures of smoking behaviormay not adequately capture these relationships. Itis also likely that this substantially increased expo-sure (and therefore higher levels of dependence onaverage) among economically deprived groups willresult in lower rates of smoking cessation, which issupported by empirical evidence.37

Tobacco exposure has traditionally been mea-sured by the number of cigarettes smoked per day.This may lead to underestimation of low SES groups’exposure to tobacco. Furthermore, higher smokingrates among disadvantaged people lead to higher ex-posure to secondhand smoke, particularly becausesmoking bans are less common in the environmentswithin which they live and work.3

There are at least two life stages when socioeco-nomic differences in smoking are particularly appar-ent: smoking uptake in adolescence and when quitattempts are made.3 International evidence suggeststhat low SES groups have the highest smoking ratesbecause they are more likely to try smoking andmore likely to become regular smokers, and are lesslikely to quit smoking.38–40

SES and smoking uptake

SES is widely regarded as being an important deter-minant of smoking uptake in young people. Parentalsmoking status, which is related to SES, has beenshown to be a predictor of smoking uptake in youngpeople.11 This reflects a mixture of influences in-cluding parental role modeling, social norms, andaccess to cigarettes/tobacco in the home. Disadvan-taged adolescents may also have difficulties with theability to resist peer pressure (and an increased levelof peer pressure given that more of their peers arelikely to smoke), lower awareness and underesti-mation of tobacco’s harm, behavior problems, andpoorer educational performance.3

Several studies in high-income countries havealso found that low SES communities have moreaccess to cigarettes through relatively higher num-bers of cigarette retail outlets and higher levels oftobacco advertising and promotion.41–46 In devel-oping countries, advertising is segmented by sta-tus, and advertisements aimed toward low SES as-sociate smoking with aspiration.47 Both marketing

placement and targeting influence smoking uptake.Banning tobacco company advertising may have astronger effect on smoking levels among low SESgiven that such advertising is often situated in dis-advantaged neighborhoods and targeted toward dis-advantaged groups.3,9

The relationship between SES and smoking up-take is generally less clear than that for smokingprevalence in adults, reflecting the difficulty of as-sessing SES among adolescents. Widely used adultmeasures of SES, such as educational attainmentand occupation, are clearly not relevant for ado-lescents. Youth smoking prevalence surveys, suchas the Global Youth Tobacco Survey, do not mea-sure SES.48 However, some surveys have devel-oped youth-oriented measures of SES, includingthe Health Behavior in School-aged Children sur-vey (HBSC). The HBSC, which is carried out in 39countries, mostly within Europe, uses a measure of“family affluence” to assess participants’ SES. The2005/6 survey found that, as with adult smoking,the relationship between youth smoking and SESvaried between countries, depending on both thestage of the tobacco epidemic in a country and ongender.49 Low family affluence was significantly as-sociated with weekly smoking among girls in nearlyhalf the countries, but in only a few countries amongboys. This pattern was strongest for girls in countriesin stage four of the tobacco epidemic (North andWestern Europe, Canada, and the United States).32

In Eastern and Southern Europe (mostly stage threecountries such as Ukraine, Estonia, and Russia),family affluence was generally not associated withsmoking. Fifteen-year-old girls from low-incomefamilies in northern Europe were also more likelyto have started smoking earlier—that is, at age 13 oryounger.

Several other studies, mostly in high-incomecountries, have also found that smoking uptake re-flects adult patterns of smoking and SES, with mostfinding higher smoking uptake among low SES ado-lescents.50 In the United Kingdom, for example, sec-ondary school students entitled to free school meals(i.e., from on low-income families) are more likelyto be regular smokers.11 Early school-leavers are alsomore likely to be smokers than those that stay on atschool.51 Studies in the United States and UnitedKingdom have also shown how the relationship be-tween SES and smoking uptake may be even morepronounced when other aspects of disadvantage and



diversity are included, such as racial/ethnic dispari-ties and social exclusion.51,52

The picture in low- and middle-income coun-tries is less clear due to the relative lack ofinternational or comparable national surveys inthese countries. From the studies that have been un-dertaken, it would appear that, as in high-incomecountries, the relationship between smoking up-take and SES reflects that observed in adults. How-ever, this is complicated by urban/rural differencesand, in some countries, traditional forms of tobaccouse. There is also some evidence that, as in manyhigh-income countries, smoking uptake in low- andmiddle-income countries may be related to low SES.For example, studies in India and China have foundthat the type of school that a young person attended,a proxy measure of SES, was related to smokinguptake. A study of middle- and high-school stu-dents in seven Chinese cities found that students athigh academically ranked schools were less likely tosmoke than those at academically low-ranked andprofessional schools.53 A study of sixth and eighthgrade students in two cities in India found that thoseat private (middle- to upper-income) schools wereless likely to use tobacco than those at government(low- to middle-income) schools.54 One of the fewstudies carried out in Africa found that among 13-to 18-year-old school students in Ghana, those oflow SES were more likely to use tobacco.55 Theform of tobacco use varied depending on how SESwas measured. Those with low material affluencewere more likely to chew tawa (traditional smoke-less tobacco), while those with lower parental edu-cation were more likely to use both tawa and smokecigarettes.

Despite difficulties in measuring SES in adoles-cent populations, where differences are found, itdoes appear that, in many countries, uptake is higherin disadvantaged groups, though this may differ bygender and form of tobacco use.

SES and smoking cessation

In addition to uptake, an obvious explanation forobserved differences in smoking prevalence by SESis a social gradient in smoking cessation. Althoughsmoking rates have been declining in the developedworld, declines have been slower or nonexistentamong low SES groups so that inequalities in smok-ing rates have increased.24,39,56–61 Even in countrieswhere smoking cessation services are widely avail-

able and have successfully targeted low SES groups(such as in the United Kingdom),62 inequalities havenot yet declined, although they may have stabi-lized.12,25 Disadvantaged smokers are also less likelyto quit in the rest of the world, although rates ofquitting are lower irrespective of disadvantage.3

Successful attempts to stop smoking usually con-sist of several processes, with the potential for SESdifferences at each stage. SES in the Toolkit is mea-sured using an occupation-based measure (socialgrade), where A is the highest social grade and E isthe lowest. The English Smoking Toolkit data havenot shown a difference in the extent to which quitattempts are made by social grade.15 However, a sig-nificant social gradient was observed in the successof quit attempts made. Among smokers who madea quit attempt in the last year, 20.4% of those froma higher social grade (A, B) were still not smokingcompared with 11.4% of those from the lowest so-cial grade (E).15 The lack of association between SESand quit attempts but observed differences in quitsuccess now seems an established finding in severalcountries.63

Multiple disadvantage is likely to reduce thechances of successful cessation further:37,64 for ex-ample, blue collar unemployed persons are less likelyto quit than white collar unemployed persons. Thereare also some suggestions that, at least in some con-texts, current tobacco control may be least effectiveamong disadvantaged women.65–67

Smoking in pregnancy is more common amongdisadvantaged women, and studies of cessation inpregnancy have found a similar social gradient inquitting as that found in the general population.In the United Kingdom, in a national survey in2005, for example, mothers in managerial and pro-fessional occupations were the least likely to havesmoked before or during pregnancy (19%), whilethose in routine and manual occupations were themost likely to have smoked (48%). In addition, thosein managerial and professional occupations weremore likely than those in routine and manual oc-cupations to have given up at some point beforeor during pregnancy (64% and 40%, respectively).Mothers in routine and manual occupations weremore than four times as likely as those in manage-rial and professional occupations to have smokedthroughout pregnancy.68 Similar differences havebeen found in other developed countries. Smok-ing cessation programs for pregnant women can be



successful, however, and there is some evidence thatapproaches tailored to the needs of disadvantagedpregnant women can be effective.69–70

Why are disadvantaged smokers less likely toquit?In general, smokers with low SES are less likely toquit smoking than the more affluent, even thoughthey are just as likely to try to stop. Smoking be-havior is mediated by the social and material con-text through psychosocial factors; these are conduitsthrough which social stratification exerts its effectsthrough fostering unhealthy habits and neuroen-docrine disturbances.71 Explored psychosocial trig-gers to cessation that may differ by SES include lackof support, greater addiction to tobacco, less mo-tivation to quit, lower adherence to treatment, lifestress, differences in cognition and perception, andtobacco industry marketing (features of cessationprograms may also favor high SES groups, such aswho is responsible for referral and whether the for-mat of a smoking cessation behavioral interventionis a group or one to one; however, there has not beenany substantial research on this to date).2,17,37,72–73

For each mechanism, the extent to which it is linkedto smoking cessation, whether it is patterned bySES, and which tobacco control interventions mayaddress it, are discussed here.

Social support. A review concluded that social sup-port exerts the greatest effect on quit attempts whenit is continuing and nondirective.74 In a qualita-tive study, whether a person had support was moreimportant in becoming a nonsmoker than whetherhealth concerns were driving their quit attempt.75

Bringing a supportive friend or relative (a “buddy”)to cessation program meetings has been found to behelpful,76–78 but overall buddies are unlikely to addany efficacy to a good group program.79 Whethersupport is more important for women80 or men77

is also unclear.There are suggestions that low SES is associated

with lower overall social support and integration, inparticular participation in formal and informal ac-tivities, and furthermore that low SES smokers mayhave lower levels of support even than low SES non-smokers.81–84 This may reduce chances of quittingsuccessfully, as a smaller or poorer-quality socialnetwork reduces the potential for support. Thosewith smaller networks may not know quitters ormay not be ostracized for smoking in a way that is

meaningful for them.3 However, one study foundthat emotional social support and long-term rela-tionship difficulties explained little about the re-lationship between area deprivation and smokingcessation;85 thus smoking-related support may bemore relevant.

Smokers with low SES may find quitting moredifficult because they have fewer people supportingtheir quit attempt.82,86 If support is available, it canimprove quit rates among disadvantaged people aswell as the general population of smokers.87 Lackof support may be the result of a higher propor-tion of smokers in low SES smokers’ social networksand/or their spouse or partner being more likelyto smoke.88 A program undertaken by the Chinesetargeting nonsmoking mothers increased quittingamong their partners.89 Thus, nonsmokers in a so-cial network can be a powerful aid to quitting—andmay be an aid that many low SES individuals lack.SES differences in cessation may be more the re-sult of differences in the proportion of smokers insocial networks than support for a particular quit at-tempt.37 This may be because positive support hasbeen found to be more important in the short term,whereas lack of negative support (such as being inthe company of people smoking) may be more im-portant for long-term cessation.87,89,90

As a higher proportion of members of disadvan-taged smokers’ networks also smoke, there is ev-idence that low SES smokers believe the smokingrate is higher than statistics suggest, and thus theyare less aware of social pressures not to smoke.91

Furthermore, in disadvantaged communities wheresmoking is often the norm, taking up smoking maybe a way of increasing one’s social network and deep-ening social bonds.3,91 This provides endorsementfor the view that the implementation of compre-hensive smoke-free legislation should reduce healthinequalities. However, this may be compromisedto some extent by outdoor smoking facilities be-ing used more frequently and accepted in low SESworkplaces.91

In addition to lack of support to quit from friendsand relatives, it is also possible that tobacco con-trol providers are less likely to provide support. U.S.healthcare providers have been found to be less likelyto provide assistance to quit smoking to lower so-cioeconomic groups.92 However, it is possible thatlow SES smokers were reluctant to be provided withassistance.



In summary, lack of support for a quit attemptis likely to reduce the chances of success. There isevidence that low SES is associated with less support.Tobacco control interventions that attempt to attacksmoking being perceived as a norm may increasecessation support, such as smoke-free policies.

Addiction/nicotine dependence. Addiction meansloss of control over drug use.93 The evidence sug-gests that the majority of smokers in the generalpopulation are highly dependent on tobacco.57 De-spite being highly motivated to quit smoking andbeing aware of the threat to health, many regularsmokers are unsuccessful in their quit attempts.57,94

Increased addiction, generally measured throughthe Fagerstrom Test of Nicotine Dependence,95 hasbeen found to reduce the chances of quitting.86,96,97

It may be a stronger predictor of cessation thanmotivation.98

In the International Tobacco Control Survey,which compares smoking and the effect of tobaccocontrol policies across a number of countries, foundthat low SES smokers were found to be more highlyaddicted.99 Addiction has been found to explainsome of the relationship between SES and quit-ting.100 This may be partly the result of low SESsmokers taking up smoking earlier and smokingmore cigarettes per day.3 They may be more likely tosmoke cheaper brands and hand-rolled tobacco.101

Hand-rolled cigarettes often contain a higher nico-tine level, which can increase addiction.102,103

Some studies have not found addiction to be partof the pathway between SES and smoking cessa-tion.37,72 A tobacco control intervention that maymitigate the likelihood of stronger addiction reduc-ing the chances of successful quitting, even amongdisadvantaged smokers, is the provision of phar-macotherapy such as nicotine replacement therapy(NRT), bupropion, or varenicline.98,104

Motivation. Sufficient motivation to stop smok-ing has been found to be a central factor underly-ing smoking cessation,75 but it has also been sug-gested that it is the balance between addiction andmotivation that is key; motivation may be moreimportant in the impetus for making a quit at-tempt rather than as a way of achieving long-termabstinence.98

Small but significant SES differences have beenreported in one’s motivation to quit.63 Those fromlow social grades are less likely to have a “desire” to

quit, to intend to quit, or to have a sense of dutyto quit.13 There were only small differences foundin motivation to quit by income, but not by educa-tion, in a Norwegian study.105 Motivation to quit,although a predictor of quitting, was not found tobe an important factor behind SES differences inlong-term quit rates in a study of National HealthService (NHS) Stop Smoking Services in Englandand Scotland.37

Motivation is likely to be most effective when itis autonomous rather than controlled by others;106

thus if smokers take onboard that smoking can dam-age their health, they are likely to be more motivatedto quit rather than if they see tobacco control ef-forts as government nagging. Higher skepticism hasbeen reported among low SES smokers regardingthe need for tobacco control and the usefulness ofavailable support.73,107 Disadvantaged smokers ap-pear to be more concerned with current mattersthan future issues—sometimes termed as increased“delay discounting” or a reduced “temporal hori-zon.”108 Thus, concerns about current health area common trigger for a quit attempt among lowSES smokers,17,109 whereas understanding and con-cern about future health issues tend to be lowerin this group of smokers;82 thus, future health con-cerns are more commonly a trigger for quit attemptsamong high SES smokers.17 This may partly explainwhy concerns about the health impact of tobaccocan be a strong motivator,110 but are less so amongsome low SES smokers.82,111 Highly emotive adver-tisements and pictorial warnings on cigarette pack-ages may be most effective in motivating low SESsmokers, as this may make health concerns seemmore immediate and such displays do not requireliteracy.112,113

It is probable that cost will affect low SES smokers’motivation to quit. Increasing the price of tobaccois likely to increase quit attempts, whereas havingto pay for smoking cessation products or programsappears to be a disincentive for using them.107,114,115

Overall, some evidence suggests that motivationmay play a role in determining who quits smoking.There is some evidence that low SES groups mayhave less motivation, perhaps due to differences inthe salience of tobacco’s threat to health. Tobaccocontrol interventions that may increase motivationto quit include increasing the price of cigarettes andcreating a more supportive environment for quittersby introducing smoke-free laws.



Exposure to stress and psychological differences.Low SES smokers are more likely to cite being ner-vous/restless or depressed as a reason for relapsethan high SES smokers.109,116 This may reflect morestressful lives.117 Low SES is associated with workenvironments with higher levels of boredom andstress118 (although Scandinavian data suggest this isnot a major mediator between SES and cessation119)and more stressful living environments inside thehome and the outside neighborhood with moreimmediate concerns that supersede smoking ces-sation.72,82,120 Smokers in these situations can viewsmoking as a comfort enabling them to cope.117,121

Tobacco control interventions are unlikely to be ableto counter embedded life patterns and underlyingstress-causing conditions such as income instability,poor housing, and run-down neighborhoods.61,115

In fact, a stress management intervention was lesseffective in a disadvantaged area with higher stresslevels.117 Upstream interventions are required thatreduce inequalities generally.22 These are most likelyto occur with strong public bodies and individualchampions.122

Previously it was suggested that disadvantagedpeople’s perception of smoking (i.e., as a copingmechanism) may reduce the chances of quitting.People’s understanding and processing of the world(cognition) and its relationship with SES and smok-ing perhaps has not received enough attention.Stressful and disadvantaged lives may reduce agencyor self-efficacy, which may spill over to reduceconfidence in one’s ability to quit and overcomebarriers to quitting.3,72,123 A recent New Zealandlongitudinal study has found that after taking intoaccount childhood SES and IQ, self-control assessedin childhood predicted smoking uptake and adultSES.124 Thus, psychology—in terms of self-efficacyand self-control—and SES are intertwined.

Furthermore, the perceived power differential be-tween tobacco control personnel and low SES clientsis wider than for high SES clients.61 For example,low SES smokers may object to feeling judged:107,125

in the support section, it was noted that high SESsmokers are more likely to feel ashamed of smoking,whereas low SES smokers often see smoking as thenorm91—thus it may be a greater step for them tobe interested in and submit to tobacco control.

It has been argued that in various countries theSES indicator that shows the greatest disparity insmoking outcomes is education.31 However, the ex-

tent to which education operates as an indicator ofSES or as a mechanism in its own right, as suggestedby differences in delay discounting and self-controldiscussed previously, is ambiguous.126 PsychologicalSES differences may possibly be addressed by edu-cation:124 the advantages of deferring gratificationmight be addressed by mass media campaigns, anddeficiencies in self-control, and self-efficacy should,in theory, be addressable by behavioral support inthe form of counseling. However, it is also likely thatchanges in wider society outside tobacco control willbe necessary.

Exposure to tobacco company targeting. Tobaccocompanies deliberately market brands toward thosewith low education and those who are less willingto make choices for future gain.46 In addition toaffecting uptake, it is also likely that industry mar-keting, such as point of sale advertising, tailoringprice, and packaging, makes cessation more diffi-cult, but little research has addressed this, particu-larly studies differentiating between SES groups.127

A study in four developed countries found thatmarketing regulations reduced awareness of pro-smoking cues more or less equally among socioeco-nomic groups.128 In addition to marketing, tobaccocompanies have also built relationships with work-ing class/blue collar trade unions through financialsupport and through framing issues to gain unionsupport of the tobacco industry’s position.129 To-bacco companies are also aware of the relevance ofcost to disadvantaged smokers and are increasinglyusing price promotions that reduce the success oftobacco control initiatives.130

Thus, it appears that the tobacco industry is awareof psychological SES differences and exploits thesein marketing campaigns. Tobacco company actionscan reduce the chances of success of any tobaccocontrol intervention.

Adherence to treatment. Adherence to smokingcessation treatments involves either taking pharma-cotherapy as directed and/or attending all scheduledsessions of a smoking cessation program. Adherenceto pharmacotherapy has been found to increase thechances of cessation.131,132 However, estimates ofadherence suggest that more than half the smok-ers do not comply.131,133 Reasons for nonadher-ence may include the tenacity of withdrawal symp-toms despite pharmacotherapy, adverse reactions,



Figure 1. Model of relationship among mechanisms encouraging smoking in low SES, tobacco control interventions, and chancesof quitting smoking.

negative attitude, lack of knowledge, and, particu-larly for low-income countries, cost.3,133,134

Low SES patients are more likely to discontinuepharmacotherapy early.132 Their reasons for discon-tinuing are more likely to be for reasons other thanhaving stopped smoking, which is more likely tobe associated with relapse.133 Furthermore, low SESsmokers have been found to have more safety con-cerns about NRT, which has been linked to self-underdosing.135

Attending a higher proportion of sessions ofa behavioral intervention program has also beenassociated with higher chances of cessation97,136

Low-income participants have been found to beless likely to complete a program.137 Adherence totreatment was a major factor in whether smokersachieved long-term abstinence after taking part inan NHS Stop Smoking Service intervention.37 How-ever, there was an issue with causality. There wasambiguity as to whether smokers relapsed and thusdecided not to continue treatment or whether dis-continuation of treatment itself caused the relapse.

Completing treatment (pharmacotherapy or be-havioral therapy) appears to improve the chancesof quitting. Low SES is associated with lower ad-herence. Direction of causality issues needs to beaddressed. Adherence to treatment may well be en-hanced by increasing support for quit attempts, en-hancing motivation to quit, addressing lack of self-efficacy, and reducing other life stress. Thus, tobaccocontrol interventions that advance these are likely toincrease compliance.

A model of mechanisms that reduces successfulsmoking cessation among low SES persons. Spe-cific tobacco control interventions have been sug-gested to address mechanisms that are likely to re-duce quit rates among disadvantaged smokers (seeFig. 1), although in reality the situation may be morecomplex. Smoke-free legislation is likely to increasesupport for quitting, addiction can be mitigated bypharmacotherapy, psychological differences leadingto less self-efficacy can be addressed by behavioralsupport and counseling, and mass media campaigns



should increase understanding and concern aboutthe harms of tobacco. Life stress cannot be dealtwith through tobacco control but instead needs tobe ameliorated through changes in attitudes and leg-islation on inequalities. Life stress is likely to affectsupport, addiction, and psychological differences,and all these are likely to affect motivation to quit.Motivation is likely to be enhanced by increasing theprice of tobacco products. Adherence to cessationtreatments is likely to be affected by the surround-ing milieu of tobacco control, culture, legislation,and other mechanisms. Tobacco industry market-ing reduces the chance of success for all tobaccocontrol interventions. All of these mechanisms havebeen hypothesized to lead to a reduced chance ofsuccess for disadvantaged smokers attempting toquit, although more research is necessary as not allfindings corroborate their utility.37,85 Evidence forthe efficacy of tobacco control interventions is nowdiscussed.

SES and tobacco control interventionsAs the tobacco epidemic spreads, smoking is in-creasingly associated with low SES. As discussedearlier, this reflects changing patterns and trendsin both smoking uptake and cessation. While thereis now clear, strong evidence on what are effec-tive tobacco control measures for reducing smokingprevalence,6,138 relatively little attention has beenfocused on what is known about how to addresssocioeconomic inequalities in smoking. In this sec-tion, we provide evidence from reviews accom-panied by recent results from the English Toolkitstudy.

A systematic review of population-level tobaccocontrol intervention studies, published before 2006,assessed their impact on social inequalities andsmoking.139 Only 84 studies were identified, andmost of these did not look at the impact on SES.No studies on young people had looked at SES. Foradults, the strongest evidence was found for priceincreases, as this intervention may be more effectivein reducing smoking in adults on low incomes andin manual jobs. Restrictions on smoking in work-places and public places were not found to have a dif-ferential effect, but smokers in higher occupationalgroups might be more likely to change their attitudesor behavior. However, these studies were conductedbefore any country had implemented comprehen-sive smoke-free legislation.

This review was recently updated by Amos andcolleagues.12 Focusing on adults in high-incomecountries, the review expanded on the previous re-view to cover all types of tobacco control, includingmass media and cessation support. Similar to theprevious review, they found that very few studieshad considered the equity impact of tobacco controlinterventions. Only 93 articles (9 reviews and 84 pri-mary studies) met the inclusion criteria. There waslittle review-level evidence other than for mass me-dia campaigns. Most of the primary studies focusedon individual cessation support. The limited evi-dence considerably constrained what conclusionscould be drawn about the types of interventionsthat could reduce socioeconomic inequalities insmoking.

Among population-level interventions, increas-ing the price of cigarettes was the policy most likelyto reduce the high level of smoking among disad-vantaged people. This is reinforced by analysis of theEnglish Toolkit survey data. When asked what trig-gered their latest quit attempt, low SES respondents,when compared to high SES respondents, were morelikely to cite the cost of smoking.17,109 Internationalevidence suggests that a 10% increase in price re-duces smoking by up to 8% in low- and middle-income countries and 4% in high-income coun-tries.3 High prices also discourage smoking amongyoung people, so in addition to encouraging cessa-tion, price increases have the additional benefit ofreducing uptake.3 There are, however, difficulties inimplementing higher tobacco taxes in low-incomecountries. Tobacco companies use their influence toprevent them, and tobacco may be grown in suchcountries, so tobacco workers would need to beredeployed if tobacco sales fell. However, tobaccotaxes, especially where proceeds are ring-fencedinto health programs, are supported by the generalpopulation.3

The next strongest evidence was for mass me-dia and smoke-free policies. There was review-levelevidence that mass media campaigns can have a neg-ative or neutral equity effect. However, more recentresearch140,141 suggests that certain types of cam-paigns that are tailored to low SES smokers couldhave a positive equity effect.

There was clear evidence that comprehensivesmoke-free legislation removes inequalities in pro-tection from second-hand smoke, which are foundwith voluntary or partial policies. The evidence



for smoke-free legislation on the equity impact onsmoking behavior was more equivocal. It has beenhypothesized that smoking bans can act as spe-cific triggers to make a quit attempt; for example,Toolkit data have also been used to examine therole of the UK ban on smoking in public placesin 2007 on prompting cessation attempts. Therewas a temporary increase in cessation attempts fol-lowing the legislation; however, no social gradientwas observed.142 An evaluation of the effect of thesmoke-free legislation in Scotland implies that moredisadvantaged smokers quit than would other-wise have been the case.5 For other population-level interventions (social marketing, restrictionson marketing, combating smuggling, smoke-freehomes interventions, financial incentives), the ev-idence was judged as insufficient or none wasfound.

Among individual-level cessation support inter-ventions, there was strong evidence that, when ef-fectively targeted at low SES smokers, services pro-viding combined behavioral and pharmacologicalsupport can have a positive influence on smok-ing inequalities, notwithstanding the adherence is-sues referred to previously. The evidence was muchmore limited on what impact, if any, this might haveon smoking prevalence at the population level. Forother types of cessation support (brief interventions,behavioral or pharmacotherapy only, Internet, quitlines, incentives, other types of support), the evi-dence was either insufficient or interventions werejudged as likely to have a neutral or negative equityimpact. Analysis of the English Toolkit data, for ex-ample, suggested that the differences in quit successby social grade were not attributable to use of ces-sation aids, with no difference among social gradesin use of NRT over the counter, bupropion, vareni-cline, or NHS counseling.15 There was a significantdifference in use of NRT on prescription, but thosefrom lower social grades were more likely to obtainNRT in this way.15,16

Given this limited evidence base, there is an ur-gent need for new studies, using a range of study de-signs, to assess the equity impact of tobacco controlpolicies and interventions at national and local lev-els. This should include natural policy experimentsacross and within countries, particularly where in-novative polices are being implemented (e.g., plainpackaging). There is also a need to extend this re-search to low- and middle-income countries where

the research base is weakest but the future challengesfor tobacco control are the greatest.

Conclusions

Smoking prevalence is generally higher among dis-advantaged groups, and these groups may facehigher exposure to tobacco’s harms. There are sug-gestions that uptake is higher among low SES, andthere is strong evidence that quit attempts are lesslikely to be successful. Studies have suggested thatthis may be the result of reduced support for quit-ting, low motivation to quit, stronger addiction totobacco, psychological differences such as lack ofself-efficacy that quitting is possible and in recog-nizing the future potential of harm from tobacco,increased likelihood of not finishing courses of phar-macotherapy and behavioral support, and targetedmarketing by tobacco companies. Evidence of inter-ventions that work among low SES is sparse. Previ-ous reviews3,9 have tended to recommend measuresthat have been tested population-wide rather thanidentify those that have particular efficacy for lowSES, probably because of the difficulty in ascertain-ing them. In this review, we have summarized theevidence that does exist. Pricing tobacco productshigh appears to be the tobacco control interventionwith the most potential to reduce health inequali-ties from tobacco. Targeted cessation programs andmass media interventions can also reduce inequali-ties. Conclusions are, however, hampered by lack ofresearch, particularly that of good quality.

The model of mechanisms and interventions de-veloped in this article suggests that pricing worksby increasing motivation to quit, which is a reason-able assumption as low SES populations have lessdisposable income. The highest smoking rates areoften among those who struggle even to be able toafford food.143–145 Money that is spent on cigarettescannot be spent on other things that might in-crease wealth or health, such as children’s educa-tion, healthcare, or other opportunities for advance-ment.3,143,146 Tobacco use traps smokers in poverty.Despite this, quitting is less frequent among disad-vantaged smokers, and future price changes havethe most potential in countries that currently havelow tobacco taxes;2 therefore, other approaches areneeded.

Tailored cessation programs appear capable of re-ducing inequalities. Such programs address two is-sues according to our model: stronger addiction,



through pharmacotherapy, and reduced self-efficacy, through counseling. Targeted mass mediacampaigns can be effective perhaps through theirability to increase awareness of the harms of to-bacco. Evaluations of the effectiveness of smoke-freelegislation show a reduced exposure to second-handsmoke but as yet do not indicate a marked reductionin smoking among low SES.

In the future, tobacco control interventions couldbe made more effective among low SES groupsthrough strict enforcement, removal of financialbarriers, and tailoring campaigns and services todisadvantaged groups—for example, by recruitingtobacco control personnel locally and targeting ge-ographically.2 Our model suggests that different in-terventions target different mechanisms that pro-duce higher use of tobacco in disadvantaged groups.Thus, a tobacco control strategy that uses a combi-nation of interventions is likely to be most effective.

Studies included in this review also suggest thatdisadvantaged smokers often perceive smoking asa coping mechanism to deal with stressful lives.Tobacco control interventions do not directly dealwith this, nor should they be expected to. This canonly be addressed by setting tobacco control withinwider social policies to reduce inequalities.2,29 Fur-thermore, to prevent heightened smoking rates, in-terventions may be needed early in life to preventSES inequalities from developing or lessening theirinfluences.147

The SES gradient in tobacco smoking is puttinglives at risk, particularly as tobacco use is growingfastest among low-income countries,3 and there islittle to suggest that inequalities in tobacco use aredeclining anywhere. We reiterate the call for sus-tained long-term monitoring of SES differences intobacco use throughout the world2,3 and for moreprimary studies that include SES in their analysis.There are many unanswered questions: why (andeven how) are smokers continuing to smoke in sim-ilar numbers when smoke-free legislation is enacted,to what extent is education a marker for SES or alter-natively a mechanism by which the understandingof the world is enhanced to reduce the threat fromtobacco, what can be substituted as a coping agentin place of tobacco for those with stressful lives, andindeed how can stress itself be reduced?

Thus, to tackle the high prevalence of smok-ing among disadvantaged groups, tobacco controlmechanisms must not be viewed in isolation but

rather as part of a comprehensive strategy to re-duce smoking. Furthermore, tobacco control itselfshould be embedded in wider attempts to addressinequalities.

Acknowledgments

All authors are members of the UK Centre for To-bacco Control Studies (UKCTCS), a UK Centrefor Public Health Excellence. Funding to UKCTCSfrom the British Heart Foundation, Cancer ResearchUK, the Economic and Social Research Council,the Medical Research Council, and the National In-stitute of Health Research, under the auspices ofthe UK Clinical Research Collaboration, is grate-fully acknowledged. The authors would like to thankGary Fooks and Behrooz Tavakoly, also of the UKCentre for Tobacco Control Studies, for providingsupplemental information.

Conflicts of interest

The authors declare no conflicts of interest.

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Socioeconomic status and smoking: a review

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