In the early decades of the smoking epidemic, smoking was more common among affluent social groups than among people with lower socio-economic status1. However, as awareness of smoking’s health risks grew, over a period of decades, this pattern started to reverse and smoking prevalence started to drop among the more educated and higher-income groups. Various studies have provided robust evidence of the association between smoking and lower socio-economic status (SES), both for men and women and across most geographic regions2.
This article summarises the latest evidence on the association between smoking prevalence and socio-economic background using data from the EHIS 2019.
The figure below shows the prevalence of daily smokers by income group, separately for men and women. In all countries, except Bulgaria and Romania, the prevalence of male daily smokers was significantly higher among people with an annual household income falling in the bottom 20 percent of the income distribution compared to the top 20 percent. Averaging across EU Member States, male smoking prevalence at the bottom of the income distribution was 11 percentage points higher than male smoking prevalence at the top of the income distribution. A similar negative correlation between smoking rates and income level can be observed among women. Nevertheless, in seven countries, namely Italy, Portugal, Croatia, Cyprus, Lithuania, Romania and Bulgaria, the prevalence of female daily smokers was larger among people at the higher end of the income distribution. Averaging across EU Member States, female smoking prevalence at the bottom of the income distribution was 3.8 percentage points higher than female smoking prevalence at the top of the income distribution.
A similar inverse relationship was found between education levels and smoking. Male smoking prevalence among individuals with less than primary, primary or lower secondary education was 25.2% in 2019, 9.9 percentage points higher among male individuals with tertiary education (15.3%). The difference is less striking among females. Smoking prevalence among women with less than primary, primary or lower secondary was 2.6 percentage points higher than the rate among women with tertiary education (14.4% vs 11.8%)3.
Since lower socio-economic conditions are associated with higher smoking rates, it is natural to think that also exposure to second-hand smoke increases among individuals belonging to groups with lower income levels. Nonetheless, the data exhibit high cross-country variability. While in numerous countries prevalence of individuals exposed to daily indoor smoke was significantly higher among people with an income in the bottom 20 percent of the income distribution compared to the top 20 percent, in many other countries the opposite holds. Averaging across EU MS, the difference in the prevalence rate of indoor smoke exposure for people at the bottom and end of the income distribution is lower than 1.5 percentage points.
Several factors contribute to the correlation between smoking prevalence and lower socio-economic status. Individuals in economically disadvantaged areas often experience increased stress due to financial instability and adverse living conditions, leading to higher smoking rates, and are less likely to quit, as a coping mechanism4. This makes it even more challenging to quit as nicotine cravings increase stress5. Furthermore, lower levels of education within these populations can result in reduced awareness of the health risks associated with smoking6 and the benefits of cessation7. Social norms in lower socio-economic communities may also be more accepting of smoking, further reinforcing its prevalence8.
Interventions aimed at reducing smoking should consider the role played by socio-economic factors on tobacco use and cessation and should be targeted at reducing these inequalities. Examples of best practice interventions include increasing tobacco taxes, due to the high price sensitivity of lower-income groups9; targeted smoking cessation programs; and comprehensive tobacco advertisement and promotion bans.
- Curbing the Epidemic, Governments and the Economics of Tobacco Control. 1999. The World Bank. ↩︎
- World Health Organization. Systematic review of the link between tobacco and poverty. Geneva: World Health Organization; 2014. Available from: http://www.who.int/tobacco/publications/economics/9789241507820/en. ↩︎
- https://ec.europa.eu/eurostat/databrowser/view/hlth_ehis_sk1e__custom_13907850/default/table?lang=en&page=time:2019 ↩︎
- Tsourtos, G., Ward, P. R., & Muller, R. (2008). Smoking and stress: the double-edged sword of living in a disadvantaged area. Australasian Medical Journal, 1(1), 1-17. ↩︎
- McKee, S. A., Sinha, R., Weinberger, A. H., Sofuoglu, M., Harrison, E. L., Lavery, M., & Wanzer, J. (2011). Stress decreases the ability to resist smoking and potentiates smoking intensity and reward. Journal of psychopharmacology, 25(4), 490-502. ↩︎
- Sikjær, M. G., Hilberg, O., Fløe, A., Dollerup, J., & Løkke, A. (2018). Lack of awareness towards smoking-related health risks, symptoms related to COPD, and attitudinal factors concerning smoking: an Internet-based survey conducted in a random sample of the Danish general population. European Clinical Respiratory Journal, 5(1), 1506235. ↩︎
- Broms, U., Silventoinen, K., Lahelma, E., Koskenvuo, M., & Kaprio, J. (2004). Smoking cessation by socioeconomic status and marital status: the contribution of smoking behavior and family background. Nicotine & Tobacco Research, 6(3), 447-455. ↩︎
- Hiscock, R., Bauld, L., Amos, A., Fidler, J. A., & Munafò, M. (2012). Socioeconomic status and smoking: a review. Annals of the New York Academy of Sciences, 1248(1), 107-123. ↩︎
- Thomas, S., et al. (2008). Population tobacco control interventions and their effects on social inequalities in smoking: systematic review. Tobacco control, 17(4), 230-237. ↩︎