Pathways of disadvantage and smoking careers: evidence
and policy implications
Hilary Graham, Hazel M Inskip, Brian Francis, Juliet Harman
............................................................... ............................................................... .
See end of article for
Professor H Graham,
University of York, Area 2,
Building, York YO30 6AS,
Accepted for publication
10 June 2006
J Epidemiol Community Health 2006;60(Suppl II):ii7–ii12. doi: 10.1136/jech.2005.045583
Objectives: To investigate in older industrialised societies (a) how social disadvantage contributes to
smoking risk among women (b) the role of social and economic policies in reducing disadvantage and
moderating wider inequalities in life chances and living standards.
Methods: Review and analysis of (a) the effects of disadvantage in childhood and into adulthood on
women’s smoking status in early adulthood (b) policy impacts on the social exposures associated with high
Main results: (a) Smoking status—ever smoking, current smoking, heavy smoking, and cessation—is
influenced not only by current circumstances but by longer term biographies of disadvantage (b) social
and economic policies shape key social predictors of women’s smoking status, including childhood
circumstances, educational levels and adult circumstances, and moderate inequalities in the distribution of
these dimensions of life chances and living standards. Together, the two sets of findings argue for a policy
toolkit that acts on the distal determinants of smoking, with interventions targeting the conditions in which
future and current smokers live.
Conclusions: An approach to tobacco control is advocated that combines changing smoking habits with
reducing inequalities in the social trajectories in which they are embedded. Policies to level up
opportunities and living standards across the lifecourse should be championed as part of an equity
oriented approach to reducing the disease burden of cigarette smoking.
health policy.1Since the 1970s, tobacco use has been
increasingly regulated, with restrictions on cigarette packa-
ging, price, advertising and promotion, sales outlets, and
smoking in public places, and treatment services have been
expanded.2 3While broad ranging, these measures rely on a
common mechanism through which to achieve their effect.
The different components of tobacco control policy seek to
change smoking habits directly, by controlling the promo-
tion, purchase, and consumption of cigarettes.
The sharp fall in smoking prevalence in older industrialised
societies has been attributed to the success of this approach.3–5
However, rates have not fallen uniformly across the popula-
tion. The decline is less pronounced in early adulthood,6
among those in disadvantaged circumstances, and for
women.7–11In consequence, young adult women in disad-
vantaged circumstances make up an increasing proportion of
the shrinking population of smokers.
The paper focuses on this subgroup of smokers. It does so
to examine the case for tobacco control policies that target
not only smoking habits but the structures of disadvantage in
which they are embedded. We investigate how disadvantaged
pathways shape women’s smoking status in early adulthood,
before turning to evidence on how social policies can reduce
inequalities in life chances and living standards, not only for
women, but for the whole population.
n older industrialised societies where smoking related
diseases are the major cause of morbidity and premature
mortality, tobacco control is the cornerstone of public
DISADVANTAGED PATHWAYS AND SMOKING
Historical evidence makes clear that the commercial produc-
tion and marketing of cigarettes underlies the smoking
epidemic that first hit older industrialised societies and has
subsequently spread worldwide.12–14In Europe and the USA
for example, pipes, cigars, snuff, and chewing tobacco were
the dominant forms of tobacco use until the late 19th
century, and levels of consumption, particularly among
women, were low.15 16In the early decades of the 20th
century, traditional products were displaced by manufactured
cigarettes, a milder and more addictive mode of tobacco
consumption.17In a pattern now being repeated on a global
scale, the new tobacco product was first taken up by higher
socioeconomic groups.10 14The smoking of manufactured
cigarettes became part of an urban lifestyle that embodied
sophistication.17 18But as the habit became more widely
adopted, its symbolic value declined and the socioeconomic
profile of smoking changed.15 16 19
Trends in the UK, where national surveys have been
tracking rates of tobacco use by social class since the 1940s,
provide an example. By the 1940s—and well before the
health risks of smoking were exposed by researchers and
were made public through health promotion campaigns—the
prevalence of cigarette smoking among men and women in
higher socioeconomic groups was already declining.16Rates
of cigarette smoking in poorer groups continued to rise until
the 1960s (men) and 1970s (women).6 16As in other societies
where smoking rates have peaked, smoking among both
women and men is increasingly a signifier of disadvantage.
Thus among women, poor childhood circumstances, as
measured by parental occupation/education, is associated
with higher rates of regular smoking and higher levels of
cigarette consumption in adolescence.20 21Both poor adult
circumstances and heavy smoking independently reduce the
odds of quitting across adulthood,22–24and in pregnancy.22 25
Socioeconomic differentials are evident across ethnic groups,
including African-American and white women in the USA,26
Maori and white women in New Zealand,3and white women
in the UK.27
Cross sectional data are the primary source of evidence on
these socioeconomic differentials. However, both women’s
circumstancesandtheir smokinghabitsare shaped
longitudinally from childhood, through the child to adult
transition, and into adulthood. Thus childhood socioeco-
nomic circumstances have an effect on the odds of persistent
smoking21and quitting28in adulthood that remains after
adjustment for adult socioeconomic circumstances. This
effect is not explained by factors related to the cultural
environment of the home, like parental education and
parental smoking or by early tobacco dependence.21 23
Children’s circumstances powerfully influence their educa-
tional trajectories.29Educational trajectories (as measured by
age of leaving education and educational qualifications) are
associated with smoking uptake in adolescence,20as well as
with current smoking,30 31heavy smoking,32and quitting in
adulthood.24Education eliminates the effect of childhood
circumstances on these dimensions of smoking status,21 31
suggesting that childhood conditions exert their influence
Education in turn determines adult socioeconomic posi-
tion,33with poor adult circumstances adding further to the
risk of smoking in adulthood,23 30and reducing the odds of
quitting.24Adolescent smoking status has been found to
predict educational level and adult socioeconomic position,
with smoking related social mobility contributing to the
association between smoking and both educational and adult
The contribution of childhood conditions, education, and
adult circumstances to adult smoking risk is also evident
among men, although the effects of childhood conditions on
women.28 35 36But research is uncovering an additional
dimension to women’s socioeconomic lifecourse. For women,
continuities in disadvantage from childhood to adulthood are
mediated by their reproductive and domestic careers, and by
early parenthood in particular.
While rates of early motherhood vary between societies, it
is women from poorer backgrounds who are more likely to be
mothers by their early 20s and to bring up children outside a
cohabiting relationship.37 38Qualitative studies suggest that
early and lone motherhood are lifecourse strategies fashioned
out of hardship, through which women access valued
identities and supportive relationships.39 40But, like early
school leaving, they are gateways into adulthood that have
adverse consequences for both future circumstances and
smoking careers. Thus, early and lone motherhood is
associated with long term disadvantage.41 42Early mother-
hood also increases the odds of smoking and reduces the
odds of quitting, over and above the effects of childhood
conditions, education, and adult socioeconomic position.23 43
Lone motherhood also, but more modestly, increases the risk
of smoking.23 43As a result, the children of young and single
mothers are at increased risk of passive smoking: gendered
trajectories of disadvantage damage the health both of
women and their children.
A British survey of women provides illustrative evidence of
the links between lifecourse disadvantage and smoking
status.44It relies on self reported smoking status that
validation studies show are broadly reliable,45with no
systematic socioeconomic bias in underreporting.46Located
in southern England and representative of its study popula-
tion, most of the survey participants are white (94%).
Participants were interviewed between 1998 and 2002, and
we focus on those aged 22–34 years (n=9936).
Four lifecourse markers were used: childhood disadvan-
tage (father in routine/semi-routine occupation at birth or no
contact with father, 38% of the sample), educational
disadvantage (leaving full time education (16 years, the
minimum school leaving age, 41%), early motherhood (by 22
years, 18%), and severe adult disadvantage (reliance on
means tested welfare benefits, 18%). In the UK, these
benefits provide an income appreciably below the EU poverty
Table 1 describes the overall rates of ever having smoked
(>1 cigarette/day for >1 year), current smoking (>1
cigarette/day), heavy smoking (current smoker >15 cigar-
ette/day), and former smoking (ever smokers not currently
smoking). It then maps the association between disadvan-
taged trajectories and these dimensions of smoking status.
Cumulative exposure to disadvantage is associated with each
dimension. Thus, among women who have experienced
childhood disadvantage, educational disadvantage and early
motherhood and who now live with financial hardship, 76%
were ever smokers, and 63% were current smokers. For
women experiencing none of these disadvantages, the rates
were respectively 33% and 18%. Cumulative disadvantage is
also associated with higher rates of heavy smoking (56%
compared with 35% for advantaged women) and with lower
rates of former smoking (17% compared with 45%).
Disadvantaged trajectories and smoking status of women aged 22–34,
(as % of current
(as % of ever
plus left full time education
plus a mother ,22
plus adult disadvantage
none of these
993645.6 29.845.1 34.6
of being a light smoker (,15 a day) and heavy smoker
(>15 a day) compared with women non-smokers
Effect of a disadvantaged lifecourse on the odds
Odds ratio (95% CI)
Current light smoker
Left school (16
Age of motherhood ,22
Current heavy smoker
Left school (16
Age of motherhood ,22
ii8Graham, Inskip, Francis, et al
Binary logistic regression analyses confirmed that each
dimension of disadvantage contributed independently to
smoking risk, increasing the odds of ever smoking, current
smoking, and heavy smoking and reducing the odds of
former smoking (results not given). We then modelled the
effect of a disadvantaged lifecourse on these dimensions of
smoking status using multinomial logistic regression, enter-
ing lifecourse factors in their temporal sequence (childhood
disadvantage before leaving school (16, etc). Taking non-
smokers as the reference group, table 2 shows the effects of
each dimension of disadvantage on the odds of being a light
smoker (,15 cigarettes/day) and heavy smoker (>15
cigarettes/day) in the fully adjusted model. A value .1
shows that the dimension increases the odds of being a light/
heavy smoker compared with the odds of being a non-
smoker. Thus, compared with non-smokers, leaving full time
education at the minimum leaving age increased the odds of
light smoking by a factor of 1.71 and of heavy smoking by
2.31. Becoming a mother before 22 years further increased
the odds of these outcomes, by 1.34 and 1.95 respectively.
Confirming patterns found in other studies, table 2
illustrates how women’s smoking careers develop, and are
sustained, along disadvantaged trajectories. While evident for
light smokers, the long term and cumulative effects of
disadvantage are more pronounced for women smoking more
than 15 cigarettes a day.
DISADVANTAGED PATHWAYS AND SMOKING
CAREERS: POLICY IMPLICATIONS
Evidence linking women’s smoking habits to pathways of
disadvantage can help guide tobacco control policies not only
for women but for the population as a whole. These policies
currently focus on the proximal determinants of smoking: on
improving knowledge of tobacco’s harmful effects, increasing
motivation and self efficacy and, through pharmacological
therapies, reducing nicotine dependence. While evaluations
and meta reviews suggest that these interventions can be
effective, there are reasons to doubt whether, on their own,
they can break the link between lifecourse disadvantage and
Firstly, increasing investment in interventions to tackle the
proximal determinants of smoking uptake and persistence
has coincided with widening socioeconomic differentials in
smoking status in older industrialised societies.16 19It is a
trend that conforms to Victora et al’s ‘‘inverse equity
hypothesis’’, in which higher socioeconomic groups are
better placed to access, utilise, and derive health benefits
from effective interventions than poorer groups.48Secondly,
lower entry rates into, and higher exit rates from, smoking
among advantaged groups is leaving behind a smoking
population that is increasingly disadvantaged and nicotine
dependent. It should therefore be anticipated that interven-
tions successful in earlier decades may fail to achieve the
same results for current and future generations of smokers.
Thirdly, in a number of high income societies, including the
UK and the USA, inequalities in key predictors of cigarette
smoking have widened. For example, the proportion of
children living in relative poverty has risen sharply in both
countries since the 1970s49; at the same time, the influence of
family background on educational attainment, and of
attainment on occupation, has increased.29 33Inequalities in
living standards in adulthood have also widened.50The
relative position of disadvantaged smokers has therefore
worsened, a trend likely to make it more difficult for
interventions to reduce smoking rates in poorer groups.
The link between social disadvantage and smoking status
argues for a new approach to reducing smoking prevalence.
Specifically, it argues for a concept of tobacco control that
looks beyond changing smoking behaviour to moderating the
social conditions that shape it. This broader concept shifts the
focus from individual level interventions to societal level
Measuring the impacts of social policies presents its own
challenges. Policies are typically rolled out in ways that make
them difficult to evaluate using experimental research
designs; cross national comparisons, cross cohort studies,
and time series data are therefore used to map their effects on
the scale and distribution of disadvantage. Furthermore,
gender differences in policy impacts are not routinely
investigated, and smoking status is rarely included as an
outcome measure. None the less, policy analyses provide a
useful resource for strategies to narrow socioeconomic
differential in tobacco use.
Firstly, these analyses confirm the importance of the macro-
policy environment in influencing factors that predict women’s
smoking status, including childhood circumstances, educa-
tional opportunities, and adult socioeconomic position. Even in
today’s global economy, when national labour markets are
increasingly constrained by the international organisation of
production and trade, national policies have been found to
have pronounced effects on the scale and distribution of
disadvantage, in childhood and across the lifecourse.47 49
poverty (in households below 50% of
median national income before and
after tax and social transfers). Source:
Percentage of children in
Pathways of disadvantage and smoking careersii9
Secondly, analyses help to pinpoint the mechanisms
through which social policies exert their influence on people’s
lives. Across older industrialised societies, the effects are
mediated through three important instruments of redistribu-
tion: taxation, cash benefits paid through the social security
system (‘‘social transfers’’), and publicly funded services, like
education, health care, and housing.
Tax and social transfers
The impact of tax and social transfer policies is captured in
cross national analyses of child poverty. These measure a
country’s child poverty rate against the threshold of average
household income (adjusted for household size and composi-
tion) in that country. In figure 1, children in households with
an income below 50% of median income are defined as poor.
It suggests that, across high income societies, tax and
transfers reduce children’s exposure to poverty. However,
the effectiveness of these redistributive mechanisms varies.
The contrast is sharpest between the Nordic countries
(Sweden, Finland, Norway), where welfare systems are
based on the inclusive provision of cash benefits pegged to
average incomes, and systems that rely on means tested
benefits well below average incomes (the USA and UK). In
Sweden, childhood poverty rates fall by 78% (from 18% to
4%) after tax and transfers; in the USA, rates fall by 26%
(from 27% to 22%).
Welfare reform has been vigorously pursued in the USA,
where single mothers are the principal beneficiaries of
transfers through the social assistance system. The major
social assistance programme was replaced in 1997 with one
designed to encourage single mothers into the labour market
through a package of support (for example, help with job
searching and vocational training). Evaluation suggests that
the welfare to work programme lifted employment rates and
incomes, with effects still evident six years later.52However,
while these effects suggest that women’s financial circum-
stances improved, cross sectional studies of the smoking
status of single mothers before and after welfare reform
indicate that rates of current smoking were higher and quit
rates were lower in the post-reform period.53As the authors
note, the financial gains of moving into paid work are likely
to be offset by social costs, including poor working condi-
tions, shiftwork, and childcare difficulties, which may work
against positive changes in smoking behaviour.
Since 1997, the UK government has also pursued major
welfare reform, using the tax and transfer system as policy
levers through which to improve the socioeconomic circum-
stances of children in low income families. The changes have
combined to raise employment rates among single mothers,54
reduce child poverty,55and increase spending by poor families
on resources that promote child welfare (children’s clothes
and shoes, fruit and vegetables, toys, books, etc).56The
improvement in family circumstances has also been asso-
ciated with reduced household spending on tobacco and
alcohol.56Evidence at the level of the individual is limited.
However, as in the USA, it suggests that improved financial
circumstances do not, at least in the short term, result in
improvements in women’s smoking status. A longitudinal
study with data on low income mothers targeted by the
welfare programme developed a hardship scale to separate
the poor from the poorest, based on debts, essential items
that are unaffordable, and anxieties about money. Using this
scale, it assessed the effect of improved circumstances on
changes in smoking status. It found that effects depended on
the degree of initial disadvantage. For single and cohabiting
mothers who, at the baseline survey, had higher educational
levels and experienced less severe hardship, moving out of
hardship was associated with higher quit rates. But for
mothers who had previously endured severe hardship,
improved circumstances did not act as a trigger for cessation
(unpublished data). As this suggests, past disadvantage has
persisting effects on smoking careers.
Publicly funded services
This third policy instrument includes both targeted interven-
tions for disadvantaged groups and universal services for the
whole population. Educational services provide an example
of both approaches.
Targeted pre-school education programmes have been
found to have longlasting effects on the social trajectories
of poor children, improving their educational levels and
employment prospects. A widely reported case study is the
High/Scope Perry Preschool project, which randomly assigned
poor black children to receive an intensive pre-school
programme at age 3 to 5 years. At 19 and 27 years, women
enrolled in the programme had higher educational attain-
ment, lower rates of teenage births and births outside
marriage, higher rates of employment, and higher incomes
than the control group.58But while intensive interventions
can help lift poor children on to more advantaged pathways,
their life chances remain significantly poorer than those of
advantaged children not in receipt of targeted support.59
Publicly funded school systems have a larger part to play in
breaking the link between childhood and adult disadvantage.
Cross national analyses suggest that poor children fare better
under some systems than others, with the strength of the
relation between family background and educational attain-
ment varying across societies. For example, the relation is
weaker in Canada and the Nordic countries than in the UK
and USA.29Important changes in the UK’s educational
system, including the introduction of a unified system of
examinations and the rapid expansion of higher (university
level) education, have failed to promote greater inter-
generational mobility. Instead, socioeconomic differentials
in young people’s examination performance at 16 and in
entry rates to higher education have increased.29 60
What this paper adds
N Develops a perspective on tobacco control directed not
only to smoking habits but to the structures of
disadvantage in which they are embedded;
N Focusing on women, discusses evidence of how
disadvantaged pathways shape smoking status in early
N Provides examples of how policies can moderate—or
amplify—structures and pathways of disadvantage
N Sheds light on why conventional approaches to
tobacco control are unlikely to be sufficient to break
the link between social disadvantage and cigarette
N Makes the case for a ‘‘joined up’’ approach to tobacco
control, concerned with changing smoking behaviour
and the social conditions that shape it;
N Highlights how government policies—using taxation,
welfare cash benefits, and publicly funded services—
affect the social determinants of smoking
ii10Graham, Inskip, Francis, et al
Publicly funded services also include those designed to
reduce teenage pregnancy, through the provision of sex
education and access to contraceptive services. A meta-
analysis of preventive strategies concluded that they do not
reduce unintended pregnancies among young women aged
11–18.61Qualitative studies shed light on why. They suggest
that teenage pregnancy and motherhood are integral to
broader strategies through which individuals and families
build self affirming identities in the face of long term
disadvantage, with young women who face a lifetime of
hardship investing in motherhood and the social relation-
ships that it sustains.39 62Such findings underline the case
for acting directly on childhood poverty and educational
With cigarette smoking increasingly confined to poorer
groups, the tobacco control community is being urged to
identify ‘‘what messages and interventions work to get lower
socioeconomic groups to stop smoking’’.63To date, the policy
response has been to increase investment in conventional
approaches to tobacco control, extending the range and
intensity of interventions acting on the individual level
influences on smoking. However, it is possible that improved
messages and more interventions are not enough: that the
barriers lie in the social disadvantages to which recipients are
The paper has reviewed research suggesting that this is the
case. By turning a spotlight on women in early adulthood, it
has presented evidence that smoking status—including
uptake, persistence, consumption, and cessation—is influ-
enced by biographies of disadvantage. These biographies
begin with poor circumstances in childhood, and are
subsequently shaped by both educational trajectories and
reproductive careers. In line with other analyses, early school
leaving, early entry into motherhood and reliance on means
tested benefits emerged as important predictors of current
and, particularly, heavy smoking. It is important to recognise
that these patterns are mapped in observational studies, with
predictors like early school leaving serving as markers of
more complex and dynamic processes that link lifecourse
inequalities to lifestyle differences. For example, sociological
studies are uncovering the dimensions of advantage asso-
ciated with staying on at school and gaining qualifications.
Drawing on the work of Pierre Bourdieu,64they point to how
parents from advantaged backgrounds who have themselves
done well at school can provide their children with ‘‘cultural
capital’’ (linguistic and cognitive skills, self confidence, a
sense of entitlement, etc) that facilitates progress at
school.65 66Cultural capital, in turn, is likely to reinforce any
direct effects that educational success has on young people’s
smoking careers. As this suggests, interventions that focus on
individual predictors of smoking, like early school leaving,
should not be expected to have unmediated effects on
While the causal pathways are likely to be complex,
evidence on the social predictors of women’s smoking
challenges the tobacco control community to ‘‘think outside
the box’’: to focus not only smoking habits but on the social
trajectories in which they are embedded. It requires a policy
toolkit that acts on distal as well as proximal determinants of
smoking, with interventions targeting smokers and the
conditions in which they live.
As a contribution to this toolkit, we have reviewed
evidence of the impact of macro-policies and targeted
programmes on the distal determinants of smoking. Until
measures of smoking behaviour, including nicotine depen-
dence, are routinely incorporated into evaluations of these
interventions, it will not be possible to track how changes in
social conditions affect changes in smoking habits. However,
our review suggests that social interventions influence the
social predictors of smoking status, including childhood
conditions, education opportunities, and adult circum-
stances. In so doing, they mediate the effects of conventional
tobacco control interventions that seek to change smoking
This suggests that social policies are tobacco control
policies. It suggests that policies that level-up opportunities
and living standards across the lifecourse have an important
part to play in reducing socioeconomic differentials in
smoking, for both women and men. They should be
championed as part of an equity oriented approach to
reducing the disease burden of cigarette smoking.
We thank the women who took part in the Southampton women’s
survey, the SWS Study Group, and the survey staff who recruited the
women and collected and processed the data. Two JECH reviewers
provided helpful comments that were taken into account in revising
H Graham, Department of Health Sciences, University of York, UK
H M Inskip, MRC Epidemiology Resource Centre, University of
Southampton, Southampton General Hospital, UK
B Francis, J Harman, Centre for Applied Statistics, Lancaster University,
Funding: the paper forms part of a project based on the SWS funded by
Cancer Research UK, grant no C5649/A4694. The SWS was funded by
the Dunhill Medical Trust, the Medical Research Council, and the
University of Southampton.
Conflicts of interest: none.
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