As with any drug addiction, social, economic, personal and political influences play an important part in determining patterns of smoking prevalence and cessation. The past two decades have seen the increasing association of smoking with markers of social disadvantage. Tobacco use is now heavily concentrated amongst the unemployed, lone parents and those living on low incomes.
In 1994 the Policy Studies Institute report Poor Smokers highlighted the extent to which tobacco use is concentrated among the most disadvantaged families in Britain. Nearly three quarters of council tenants receiving means-tested benefits smoke, spending £16 a week - £1 in every £7 of their net disposable income - on cigarettes. The Treasury therefore recovers 17% of all income support paid to those who are parents of dependent children and who smoke. Tobacco use was also shown to be a significant additional cause of hardship among low income families with children, reducing essential expenditure. The children of poor families who smoke are three times more likely to go without essential items (e.g. footwear) than the children of similarly poor families who do not smoke (Marsh & McKay 1994).
Jarvis, using data from the British National Child Development Study (NCDS), also emphasizes the importance of the smoker's socio-economic environment in encouraging or impeding smoking cessation. He points out that there has been little change in the high smoking prevalence rates (about 70%) in the poorest groups over the last two decades. The NCDS data confirm the inverse relationship between adverse living circumstances and cessation rates which vary from 35.9% amongst the most affluent to 14.4% amongst the poorest groups. Cessation rates are particularly low amongst lone parents (12.6%) and those who are divorced, separated or widowed (11.8%) (Jarvis 1997).
While there are limited opportunities to change a person's whole social environment, treatments such as nicotine replacement offer a readily available means of targeting nicotine addiction. Bond and colleagues established that the average purchaser of NRT in Scotland is middle-aged, female, affluent and receives pharmacy support, thus confirming under-utilisation of NRT by smokers from more disadvantaged groups (Bond et al 1994). Currently NRT products are not available on prescription. This ensures that those groups which have the highest smoking rates and levels of addiction, have least access to NRT products.
In 1996 ASH Scotland - with funding and support from HEBS - established a three-year Women, Low Income & Smoking Project providing funding for community-based projects which support smoking reduction among women. Findings to date highlight the need for flexible and accessible support services for women and a need to overcome resistance to tackling work around tobacco dependency. However, at present there is insufficient evidence about the effectiveness of community interventions to make policy recommendations in this paper.