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‘Cigarettes are priority’: a qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices: Table I.

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Abstract

Despite substantial modelling research assessing the impact of cigarette taxes on smoking rates across income groups, few studies have examined the broader financial effects and unintended consequences on very low-income smokers. This study explored how socioeconomically disadvantaged smokers in a high-income country manage smoking costs on limited budgets. Semi-structured face-to-face interviews were conducted with 20 smokers recruited from a welfare organization in NSW, Australia. Participants discussed perceived impact of tobacco costs on their essential household expenditure, smoking behaviour and quit cognitions. Interviews were audio-taped, transcribed verbatim and analysed using thematic framework analysis. Instances of smoking-induced deprivation and financial stress, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes were reported as routine experiences. Price-minimization strategies and sharing tobacco resources within social networks helped to maintain smoking. Participants reported tobacco price increases were good for preventing uptake, and that larger price rises and subsidized cessation aids were needed to help them quit. Socioeconomically disadvantaged smokers engage in behaviours that exacerbate deprivation to maintain smoking, despite the consequences. These data do not suggest a need to avoid tobacco taxation, rather a need to consider how better to assist socioeconomically disadvantaged smokers who struggle to quit. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.
‘Cigarettes are priority’: a qualitative study of how
Australian socioeconomically disadvantaged smokers
respond to rising cigarette prices
Ashleigh Guillaumier
1
*, Billie Bonevski
1
and Christine Paul
2
1
School of Medicine and Public Health, University of Newcastle, Newcastle 2308, Australia and
2
Priority Research
Centre for Health Behaviour, School of Medicine and Public Health, University of Newcastle and Hunter Medical
Research Institute, Newcastle 2308, Australia
*Correspondence to: A. Guillaumier. E-mail: ashleigh.guillaumier@newcastle.edu.au
Received on November 19, 2014; accepted on May 26, 2015
Abstract
Despite substantial modelling research assessing
the impact of cigarette taxes on smoking rates
across income groups, few studies have examined
the broader financial effects and unintended con-
sequences on very low-income smokers. This
study explored how socioeconomically disadvan-
taged smokers in a high-income country manage
smoking costs on limited budgets. Semi-
structured face-to-face interviews were con-
ducted with 20 smokers recruited from a welfare
organization in NSW, Australia. Participants dis-
cussed perceived impact of tobacco costs on their
essential household expenditure, smoking behav-
iour and quit cognitions. Interviews were audio-
taped, transcribed verbatim and analysed using
thematic framework analysis. Instances of
smoking-induced deprivation and financial
stress, such as going without meals, substituting
food choices and paying bills late in order to pur-
chase cigarettes were reported as routine experi-
ences. Price-minimization strategies and sharing
tobacco resources within social networks helped
to maintain smoking. Participants reported to-
bacco price increases were good for preventing
uptake, and that larger price rises and subsidized
cessation aids were needed to help them quit.
Socioeconomically disadvantaged smokers
engage in behaviours that exacerbate deprivation
to maintain smoking, despite the consequences.
These data do not suggest a need to avoid tobacco
taxation, rather a need to consider how better to
assist socioeconomically disadvantaged smokers
who struggle to quit.
Introduction
Economic modelling studies suggest taxation may
be particularly effective in reducing tobacco use
among socioeconomically disadvantaged smokers
who have among the highest smoking rates and
appear to be the most price sensitive [1, 2].
However despite substantial price rises in many
countries, there remains a social gradient with an
inverse relationship between income level and to-
bacco use [3] and few studies have assessed the
wider and unintended consequences of tobacco
costs on highly disadvantaged smokers, particularly
using qualitative methodologies. Examining the ex-
periences and perceptions of disadvantaged smokers
may help guide the development of complimentary
strategies for those who are financially stressed to
further strengthen taxation and pricing reforms.
Price-minimization strategies can be used to
maintain and manage the rising cost of smoking.
Strategies include switching to cheaper brands,
products or sources (including illicit sources) of to-
bacco or purchasing in bulk [4]. Smokers who
engage in the use of price-minimization strategies
are less likely to make quit attempts or to success-
fully quit [4]. Additionally, socioeconomically
disadvantaged smokers are more likely to engage
HEALTH EDUCATION RESEARCH Vol.30 no.4 2015
Pages 599–608
Advance Access published 25 June 2015
ßThe Author 2015. Published by Oxford University Press. All rights reserved.
For permissions, please email: journals.permissions@oup.com
doi:10.1093/her/cyv026
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in one or more price-minimization strategies [5]. In
tightly regulated markets such as Australia’s, oppor-
tunities for purchasing lower taxed and untaxed to-
bacco are limited and buying in bulk attracts few
discounts. It is unlikely that use of these traditional
price-minimization strategies alone is enough to
manage the rising cost of smoking among highly
disadvantaged smokers living at or below the pov-
erty line.
Price increases may disproportionately burden
low-income smokers in unintended ways. Low-
income smokers in the United States [6] and low
socioeconomic status (SES) households in
Australia [7] spend significantly more of their
household funds on tobacco than their more advan-
taged counterparts. In general, smokers are more
likely to have lower levels of material well-being
compared to those who have quit successfully [8],
and smoker households are less likely to spend
money on restaurant food and health insurance [9].
This is likely to be more exaggerated among socially
disadvantaged smokers who are more likely to ex-
perience smoking-induced deprivation, spending
income on tobacco in place of household essentials
like food [10, 11]. Substantial evidence suggests that
socioeconomically disadvantaged smokers experi-
ence higher levels of financial stress associated
with their socioeconomic position, which inhibits
cessation attempts [12, 13] and success [14].
Behavioural economic theories such as the ‘im-
perfectly rational addiction model’ [15] suggest not
all smokers would intend to quit, even at very high
tobacco prices. Both the social and cultural context
of smoking, as well as individual factors may keep
low SES smokers from quitting. Research into the
dynamics of smoking in large social networks sug-
gests that as smoking prevalence has decreased over
time, smokers have clustered together and moved to
the periphery of social networks [16]. Qualitative
studies have illustrated that low socioeconomic
areas are more permissive of and conducive to
smoking behaviours [17–19]. Smoking is also per-
ceived as an important means of social inter-
action and a way of coping with the stressors of
personal circumstances and surrounding environ-
ments [17–19], even though non-smokers have
lower stress levels than smokers generally [20].
On an individual level, low-income smokers are
more likely than high-income smokers to have
shorter planning horizons [21], and low SES smo-
kers tend to be more present-oriented and impulsive
(inability to delay gratification) than high SES smo-
kers [22]. These factors may help explain why finan-
cially stressed smokers experiencing material
deprivation and hardship find it harder to achieve
cessation and continue smoking despite tobacco
price increases, however further research is needed
because of the lack of qualitative study in the area.
While substantial research supports increasing to-
bacco taxes to achieve cessation among low SES
groups [1], few have explored the resulting experi-
ence of deprivation and financial stress among those
who maintain smoking. Highly disadvantaged
groups face significant tobacco-related health and
welfare inequalities, and there is a need to under-
stand the strategies these groups use to maintain
smoking in order to develop socially responsible
policy. The aim of this project was to gain a fuller
understanding of how smokers who experience mul-
tiple and high levels of social and financial disad-
vantage conceptualize, manage and respond to the
increasing costs of smoking. Of particular interest
were the perceived effects of rising tobacco costs on
essential household expenditures, smoking behav-
iour and quit cognitions.
Methods
Design
In-depth, semi-structured face-to-face interviews
and a brief exit survey were conducted with clients
of a social and community service organisation
(SCSO) who were current smokers. Data were col-
lected in November and December 2012. University
of Newcastle Human Research Ethics Committee
approved this study.
Setting
The SCSO is a large, non-government, not-for-profit
organisation providing welfare and financial aid as-
sistance services to disadvantaged members of the
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local community. Socially disadvantaged groups
such as the long-term unemployed, people with a
mental illness, the homeless and Aboriginal and
Torres Strait Islanders are over-represented as
SCSO service users [23]. The SCSO services a
broad catchment area in south-western Sydney,
New South Wales, Australia.
In Australia at the time of the study, the cheapest
recommended retail price for a 25-pack of cigarettes
was AUD15.40 and AUD19.95 for a 30-g pouch of
tobacco [24].
Sample
Purposive sampling strategy was used to recruit
highly socially disadvantaged smokers. A conveni-
ence sample was recruited via a registry of participant
contact details from individuals who had participated
in a quantitative survey conducted by the research
team at the same SCSO site [25]. Participants were
attending the service for an Emergency Relief ap-
pointment (provision of financial and food aid),
aged over 18 years, able to speak and comprehend
English and were identified as current smokers during
a quantitative survey about the price of tobacco.
Procedure
The research assistant (RA), made telephone contact
with potential participants and invited them to par-
ticipate in an interview on their perceptions of the
price of cigarettes. The study was conducted onsite
in a private room at the SCSO. The RA conducted the
interviews. One author (AG) co-facilitated the first
two interviews, and then reviewed subsequent inter-
view audio to provide on-going feedback to the RA.
Interviewing continued until saturation of themes was
reached. Interviews were audio-taped and lasted an
average of 30 minutes. Participants completed a brief
survey at the end of the interview. All participants
were offered the opportunity to review or remove
comments from the audio. Participants received
AUD$50 grocery voucher as reimbursement.
Measures
The interview schedule was developed with consid-
eration of two sources of information. Firstly, the
available literature was reviewed to ensure the
schedule included the primary themes cited in the
existing evidence base such as price-minimization
strategies, smoking-induced deprivation, financial
stress and experience of tobacco price rises.
Secondly, the schedule development was also influ-
enced by the results of a quantitative survey con-
ducted by the authors prior to this study to ensure
that results obtained in the large survey were further
explored during these interviews. Interviews began
with questions about participants’ current tobacco
use and expenditure, where tobacco fitted within
personal budgets, and how tobacco costs impacted
on smoking behaviour and household spending. A
brief exit survey assessed: gender, age, Indigenous
status, income, income source, marital status, edu-
cation and housing.
Analysis
Interviews were recorded and transcribed verba-
tim and checked for correctness by A.G. Data
were analysed using thematic analysis by one
author (AG) using NVivo version 10. To establish
inter-rater reliability an independent researcher
separately coded 25% of transcripts, and identified
themes were compared and reconciled where ne-
cessary. Braun and Clarke’s [26] approach to the-
matic analysis was used, following a realist
paradigm, considering meanings across the
entire dataset and identifying semantic themes.
Quotes are presented to illustrate key themes;
identifiers are gender and age.
Results
Sample
In total, 57 people were called; 20 were unreachable,
and six had an inactive telephone number. Of the 31
who could be contacted, 6 declined to participate
and 25 scheduled an interview. Twenty interviews
were successfully completed (65% response rate).
Table I presents the demographic details of the 20
current smokers who participated. None of the par-
ticipants received income from paid work; all were
dependent on government benefits.
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Current tobacco use behaviour
About two-thirds of the sample reported
smoking 20 cigarettes per day. The price of cig-
arettes was the dominant factor for purchasing deci-
sions. Participants reported selecting cigarette brand
based on the least expensive pack available, pur-
chasing from the cheapest available source which
in this case is either the supermarket or a tobaccon-
ist. Most said they purchased tobacco asthey needed
it. When asked about their tobacco expenditure,
45% of participants reported spending between
AUD$50 and $80 per week, while a further 35%
spent between AUD$81 and $150. Most estimated
their tobacco expenditure was 25%–35% of their
total personal income. Half of the sample reported
never having considered the amount of money they
spent on tobacco relative to their income.
Essential expenditure and cigarette price
rises
Management of finances
Most participants reported dealing with expenses as
they arose, describing limited use of formal budget-
ing and financial planning. Putting money aside for
savings was not seen as possible ‘There’s no way for
me to save money ...I don’t have any extra money
to save’ (F27), and many expressed poor impulse
control with their money ‘I get paid on a Monday
then every Monday I’ll give my grandparents money
to hold for me until the Friday so it’s not sitting in
my wallet so we’ve got money for the weekend’
(F29). Rent, bills, groceries and cigarettes were the
most common expenses reported by participants.
Most participants reported using a government-
initiated direct debiting system that automatically
deducted rent and nominated utility bills from
their welfare payments. The remaining money was
then used to cover day-to-day living expenses
‘Everything’s coming out like bills, my rent, my
bills. Everything comes out automatically so then
what I’m left with is my food, like kids’ stuff, like
school excursions, cigarettes. They’re the only
things that I have left to pay for once all my bills
are paid ...(F27). Overall financial behaviour
seemed to be largely reactive.
Essential household expenditure was dealt with
on a ‘pay-check to pay-check’ basis. As such,
most lacked awareness of where the extra money
to pay for increasing tobacco costs came from,
simply adapting to higher prices ‘...when we
can’t afford it so much, that’s when we have to
just cut down and we found that, well then, when
we can afford it, we just slowly, sort of, starts creep-
ingbackupagain(F33) and ‘To be honest I’d prob-
ably pay that extra ...So just say my budget’s $77
[for cigarettes/week] if it was an extra $10 I would
pay the $87 or the $97’ (M47). There was a sense
given that for those who intended to continue
Table I. Demographic characteristics of the study participants
(N¼20)
Characteristic n%
Age
18–39 13 65
40 7 35
Gender
Male 7 35
Female 13 65
Aboriginal & Torres Strait Islander status
Indigenous 3 15
Non-Indigenous 17 85
Marital status
Married /De facto/living with partner 6 30
Separated/divorced 4 20
Never married/single/widowed 10 50
Highest education
Primary school 1 5
High school years 7–10 11 55
High school years 11–12 3 15
TAFE/trade qualification 3 15
University degree 2 10
Personal weekly income
$299 10 50
$300–$499 7 35
$500 2 10
Prefer not to answer 1 5
Income source
Paid work 0 0
Centrelink (Government benefits) 20 100
Housing type
Own house 2 10
Private rental 5 25
Government rental 11 55
Homeless or supported accommodation 2 10
TAFE, Technical and Further Education.
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smoking despite rising costs, it didn’t matter where
the money came from.
Cigarettes are a protected purchase
Sacrificing essential household spending to maintain
smoking behaviour was common. Half the sample
were forthcoming about prioritising cigarettes: ‘I’ll
sacrifice other stuff before I’ll sacrifice my smokes’
(M47) and ‘I’d put no matter what to get them cig-
arettes. Cigarettes are priority’ (M48). As such, for
these smokers cigarettes were the priority purchase
after getting paid ‘Normally buy me smokes then do
my groceries’ (M35). The other half of the sample
reported covering essential household expenses
before purchasing cigarettes ‘...we go buy the
food we need, see what money we’ve got at the
end and then buy what smokes we can’ (F33) and
...I mean sometimes I smoke less because...I’ve
got to buy, yeah other stuff so other bills have come
in’ (M49). These smokers were adamant they did
not compromise essential household spending for
smoking but were aware this type of sacrifice
occurred within their community ‘Most will give
up other things I think...For me I’ll cut back or
cut out. But that’s just for me’ (F65). Regardless
of whether they were the first or last purchase in
the pay cycle, cigarettes were a primary item of
expenditure.
Influence of rising smoking costs on essential
spending
Participants were generally aware that their cigarette
expenditure impacted spending in other areas ‘Not
that they [participant’s children] missed out on
clothes or food or anything like that but they do
miss out on the outings if we smoke’ (F31).
Participants listed late bill payments, going without
meals and having insufficient money for petrol,
clothing, alcohol and family leisure activities as
some of the ways rising smoking costs impacted
on other spending. When identifying specific ex-
amples of cuts to household spending, distinct dif-
ferences emerged between smokers’ accounts of
what they observed happening in their community
compared with their own behaviour. Participants
were forthcoming with examples of others’
sacrifice:
‘They’ve [neighbours] stopped their normal
routine that they used to have, weekly shop-
ping and going out and getting the things they
want, petrol, things like that, cigarettes have
taken over their budget’ (F27).
‘you see that all the time, especially in our
area where we are...you see kids not eating
and parents are smoking’ (M49).
However, they contrasted their own instances of sac-
rifice with examples that they considered to be
worse:
‘Yes friends of mine will not get their gro-
ceries so they can get their smokes...they
get behind in their bills. I mean I’ve been
behind in my bills before, bills but not food.
We refuse to...(F31).
There was a reciprocal relationship between the
stress of not having enough money to cover house-
hold essentials and smoking ‘Sometimes I’ve been in
a situation where it’s like should I buy meals or buy
smokes...Whatever way like obviously if you’ve got
no money and you’ve got no milk you’re stressing
out, so I buy smokes(M30). An exasperation with
their financial situation led to a mismanagement of
funds for some smokers ‘...you get to the point
where you’re like, ‘OK, I’ve got $20 left, I can
either put that on the electricity...or I can go and
buy a packet of cigarettes.’... The way that you’re
feeling, you’re thinking ‘I’d rather go buy the packet
of cigarettes. I’ll put the $20 on it next week’ (F33).
The solution for some was to rely on food vouchers
from community welfare organisations ‘that’s why
I’m here, that’s why I come to [SCSO name] be-
cause it helps us out with food so then I can buy
enough smokes to survive’ (M48).
Throughout discussions participants expressed
disappointment regarding their cigarette expend-
iture ‘It appals me. That I could still smoke. I hate
it’ (F29) and ‘I know that we could do a lot better
things with that money’ (F31). This may have moti-
vated some participants to distance themselves from
what they considered to be less than ideal behaviour.
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In all accounts, whether personal experience or ex-
amples of family, friends and neighbours, partici-
pants described the serious impact rising smoking
costs has on essential household spending as a
common problem among their communities. Some
speculated that increasing tobacco costs would lead
to smokers ending up ‘in debt’ (F33),’ ‘homeless or
starving’ (F27) or reduced to crime ‘I’ve heard
people say eventually if they keep putting it up it’s
just going to make them steal to get more’ (F27). The
seriousness of these outcomes indicates the strength
of addiction as well as the importance of smoking to
these individuals.
Smoking behaviour
For many participants smoking was a shared experi-
ence that established a sense of community and
formed an integral part of social behaviour.
Sharing, swapping, trading or borrowing cigarettes
was common among participants ‘...we all smoke,
we all share smokes too, if one hasn’t got one, give
me a smoke. There’s one mother tells me, I owe you
a packet, then she hit me up the other day,I gave her
a handful, she goes I don’t want a handful, I only
want one, I said take a handful, I’ll be hitting you up
by the end of the week anyway’ (F33). Overall these
practices were framed using positive language such
as ‘sharing’ and contributed to a sense of camarad-
erie among smokers. However, there was also a
sense of disdain for anyone perceived to be taking
advantage of this system by ‘bludging’ or ‘scabbing’
cigarettes. Smoking was the norm within partici-
pants’ social networks ‘we’ve got family that all
smoke too, so, you know...’ (F33). This meant that
smokers could pool their resources and rely on their
social networks for sharing or borrowing cigarettes
to manage smoking throughout the household cash
flow and spending cycle.
Price-minimization strategies
Participants discussed numerous price-minimisation
strategies used to manage the cost of smoking. Most
had switched to cheaper cigarette brands in the past;
however this strategy was no longer feasible be-
cause mine’s pretty much the cheapest there is
(F27). Switching from tailor-made cigarettes to
roll-your-own tobacco was mentioned by most smo-
kers, ‘Yeah I’m smoking rollies this week and it does
work out a lot cheaper...couldn’t do it permanently
though’ (F29). Reducing the number of cigarettes
smoked per day by ‘smoking half cigarettes instead
of full ones’ (F21) or increasing the time between
each cigarette were cited as ways to make cigarettes
last longer and save money, however some were
uncertain this was a long-lasting change ‘Itrythat
all the time, it doesn’t really happen(F29) and I
did try and cut down and I have changed my brands.
I find I cut down for a little bit but then I just go back
to my normal smoking routine(F41). Collecting
cigarette butts off the street was reported by three
smokers as something they had seen others do
...you’ll see them going and taking butts from
the cigarettes and then, oh, you’d just want to do
without...(F33). Overall, it appeared that the use
of price-minimisation strategies was a way to stretch
out tobacco supplies when money was tight.
Although participants perceived these strategies to
be temporary changes to their smoking behaviour,
they usually occurred at the end of a pay cycle indi-
cating they were being made on a regular basis and
likely formed part of their smoking routine.
Illicit tobacco
Awareness of illicit tobacco was high and most had
tried it in the past. However, it was not considered a
regular option. This was true of black market cigar-
ettes ‘It’s a lucky dip with them, I mean you don’t
know what flavour, what brand you’re getting, what
percentage of nicotine’ (M47), and ‘chop chop’
(illicit loose tobacco) ‘...anybody can add anything
to that and you wouldn’t know what’s in it’ (F29).
Many disliked the taste of illicit tobacco and, iron-
ically, worried about the tobacco quality and health
risks.
Quit cognitions
Prevention versus cessation
The sample was divided on whether increasing
tobacco prices would help smokers to quit, al-
though recognized its merit as a prevention strategy.
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If that’s the only thing that’s going to really help
yeah I think it is fair. And it stops a lot of the young
ones from taking up smoking too because they can’t
afford to smoke’ (F41). Some thought price in-
creases would be particularly useful for preventing
uptake of smoking among youth.
In terms of cessation, some participants thought
price increases would encourage smokers to con-
sider quitting ‘I mean people are going to get
cranky at first, myself included, but yeah at the
end of the day it’s going to help’ (F41). Others
thought ‘if you smoke you smoke, you’re not going
to quit just ‘cause of the price’ (F33) or that price
increases were a routine part of smoking ‘If they go
up people complain for a couple of weeks, you know
I can’t believe that went up so much. But after a
while it becomes routine. Sort of like that’s life,
they’re going to go up again’ (F29). Complaints
were made that increasing cigarette taxes was ‘a
revenue grabbing sort of exercise, instead of a quit
smoking exercise’ (M35). Although some saw the
potential prevention and cessation-related benefits
to increasing tobacco prices, many accepted price
increases as part of the smoking routine.
Quit assistance
Overwhelmingly, participants reported that smokers
needed more help to quit. Overall, when discussing
cigarette prices being used to encourage smoking
cessation, participant’s expressed a sense of longing
for the decision to quit to be taken out of the indi-
vidual’s hand ‘to be honest if they went up to the
point where I could not afford them, like if it was
going to cost me $30 for a packet of 40s I’d prob-
ably be grateful...if a pack of 25 s cost about
$20...would be ridiculous, I would have no other
option but to quit’ (F29), or ‘Around about $35/
$40...That would be enough for me. That’s when
I’d be seeing my doctor and going either give me
something real cheap so I can get off it or I’m going
to be sick of this you know I’ll put myself in hospital
and stop the cravings...and just detox. I won’t pay
that, that is jokeable’ (M48). These positions may be
indicative of a hope that at some point the cost of
smoking will outweigh the addiction and difficulty
of quitting. However, given the study sample were
long-term smokers who have continually absorbed
the increasing costs of smoking over time, these
critical price points should be interpreted with
caution.
Participants seemed to perceive policy-makers as
having the capacity to increase the provision of
smoking cessation care and initiatives and that
they should be doing more to help: ‘the money
that the government gets for tax on cigarettes is
nowhere near the money that they put into fighting
people to quit(M35). The affordability of cessation
aids such as nicotine replacement therapy (NRT)
was mentioned by a number of smokers ‘Some of
the things that you do buy to stop smoking are just as
costly as cigarettes anyway...A lot of people, they’d
say I’d rather buy a packet of cigarettes than spend
that $10 on the gum.’ (F35). Others suggested
‘outlaw it’ (F33), stopmakingthem(F29), have
more health things about it...more things on TV’
(M49), or use larger cigarette price increases ‘I think
it’s moving too slow but the increase, I think it has
warned a lot of people, but it’s not warning enough’
(F27). There was a pervasive belief that govern-
ments could be doing more and in particular that
proceeds of tobacco price increases could be used
to provide more assistance to help people quit.
Discussion
This study explored how socioeconomically disad-
vantaged smokers conceptualise, manage and re-
spond to the increasing cost of smoking.
Participants reported reducing essential household
spending, using price-minimization strategies, and
sharing, trading and swapping tobacco supplies
within their social networks to manage the increas-
ing price of tobacco. There were conflicting opin-
ions over prices being used to encourage quitting,
although participants agreed that smokers needed
more help to quit. Reducing the cost of cessation
aids was repeatedly suggested as a way to promote
cessation. Many low SES smokers quit as a result of
increased tobacco taxation [1], making tobacco tax-
ation an important tobacco control tool.
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Understanding the behaviour of those who do not
quit is important in planning how tobacco taxation
increases may impact on those who struggle to quit,
and assist in planning a more coordinated approach
to achieving the greatest possible community benefit
from tobacco control efforts.
The evidence indicates some socially disadvan-
taged smokers will reduce essential household
spending to maintain smoking on a budget that is
already limited. The majority of the sample were
living below or on the Australian poverty line
[27]. Although we had no comparison group, experi-
ences reported in the current study are supportive of
previous financial stress research findings that low
SES smokers spend higher proportions of their
income on tobacco [6, 7] and have poorer material
well-being [8] than smokers in higher socioeco-
nomic positions. In our sample, most smokers esti-
mated spending 25%–35% of their income on
cigarettes, which was often at the expense of other
essential household spending on bills, groceries,
clothing and family activities. Smoking on limited
budgets was the norm in these participants’ social
context. These behaviours are likely to compound
existing levels of social exclusion and deprivation.
Smoking is positively related to the experience of
financial hardship, which in turn is associated with
unsuccessful cessation; increases to the cost of to-
bacco may contribute to this cycle. As previously
suggested by Siahpush et al. [13] health and social
policies should be developed in tandem to relieve
circumstances of hardship.
There is a lack of understanding about the strate-
gies used by socially disadvantaged groups living on
or below the poverty line to maintain smoking des-
pite increasing prices. In previous quantitative
survey research, disadvantaged smokers endorsed
price-minimization strategies such as switching to
cheaper brands and reducing consumption as ways
to manage rising tobacco costs [28]. These behav-
iours were discussed and elaborated onin the current
study. Participants reported use of these price-mini-
misation strategies appeared to be situation specific.
Strategies were used when money was tight, but
smoking behaviour tended to return to normal at
the beginning of the pay cycle. Furthermore, these
traditional cost-cutting measures were not enough
to maintain smoking behaviours. A small number
of participants also mentioned relying on
the SCSO to provide their food, which may
contribute to increasing pressure on foodbanks.
Participants were concerned for the wellbeing
of members of their community. They worried that
if prices continued to increase this would further
exacerbate experiences of deprivation and poten-
tially lead to socially undesirable behaviour and/or
illegal activity.
In this study, participant accounts demonstrate
shared experiences that appeared to contribute to a
sense of camaraderie. Within a social context where
smoking is the norm, participants found support
within their communities and social networks to
maintain smoking. The shared experience of strug-
gling to afford tobacco meant many pooled re-
sources and relied on family and friends to share,
trade and borrow cigarettes to get by. Social norms
that are more conducive to pro-smoking attitudes
and behaviours may contribute to the difficulty
some smokers face in achieving successful cessation
[17]. Compared to traditional price-minimization
strategies, these behaviours are harder to target via
tobacco control policies. Future policies and clinical
approaches may need to consider the best ways to
engage a smoker’s socialnetworks to encourage and
support cessation.
Many participants expressed a sense of helpless-
ness toward quitting smoking. There is mixed evi-
dence as to whether disadvantaged smokers are as
interested in quitting as their more advantaged coun-
terparts [29–31]. Recent research suggests that low
SES smokers who exhibit an external locus of con-
trol, cognitive impulsiveness and steep delay dis-
counting (strong preference for smaller, immediate
rewards over larger delayed rewards) are less likely
to remain abstinent following cessation treatment
[32]. Smokers in this study expressed a wish for
an external force to motivate cessation (e.g. larger
price increases, stopping cigarette production), an
inability to control personal expenditure, and re-
frained from purchasing cessation aids due to up-
front costs. The cost of NRT has previously been
identified as a barrier to cessation among socially
A. Guillaumier et al.
606
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disadvantaged smokers [33]. Previous research in-
dicates that smokers are supportive of a dedicated
tobacco tax when the revenue is used to help them
quit [34]. Initiatives such as the promotion and pro-
vision of subsidised cessation aids, health warning
campaigns and counselling programmes could ac-
company future price increases to offset the unin-
tended negative consequences of the policy among
low SES smokers.
This research provides insight into purchasing
and budgeting patterns, and cigarette prioritisation
of smokers who experience high levels of social and
financial disadvantage in a high income country.
However, as we specifically targeted highly disad-
vantaged smokers these findings cannot be general-
ised to the experience of the general smoking
population. Additionally, the study conclusions
may not be generalizable to low income countries.
Socioeconomically disadvantaged smokers engage
in behaviours that may compound their depriv-
ation by reducing already limited essential house-
hold spending in order to maintain smoking as
tobacco prices increase. Price-minimization strate-
gies are used on an as needed basis, usually at
the end of a pay-cycle. Smokers also rely on a
system of sharing and trading resources within
their social networks to make cigarettes last longer
or to cut costs in the short-term. Although these
smokers are interested in quitting, they require
more support to do so. Effective tobacco control
policy requires a comprehensive approach where
taxation should not be seen in isolation.
Governments should consider providing and pro-
moting effective cessation aids and programs at
the time of tobacco price increases to counter the
negative consequences of rising costs and support
quit attempts.
Acknowledgements
The authors thank the Social and Community
Service Organisation and its clients involved in
this research, as well as Melinda Hickey for her
role in recruiting clients into the project.
Funding
This work was part of a project funded by a grant
from the Hunter Medical Research Institute
(G1101150). A.G. was supported by an Australian
Postgraduate Award PhD Scholarship administered
through the University of Newcastle. B.B. was sup-
ported by a Cancer Institute NSW Career
Development Fellowship. C.P. was supported by
Newcastle Cancer Control Collaboration funding.
Conflict of interest statement
None declared.
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... While this demonstrates that disadvantaged smokers are responsive to price rises, it also shows that taxation policies are not able to exert a stronger impact on this particular population, who are traditionally characterized by higher smoking rates. In response to tax increases, socio-economically disadvantaged smokers often adopt 'price-minimization' strategies to keep smoking (Guillaumier et al., 2015). For example, they buy cheaper products (e.g., roll-your-own tobacco products), share tobacco with their friends, as well as cutting back on food or delaying the payment of bills to afford cigarettes. ...
... For instance, tax increases should be combined with awareness campaigns, smoking cessation services, and increased enforcement to prevent illicit tobacco consumption. At the same time, tobacco tax regulation, as well as other tobacco control laws, should be combined with broader policies aimed at improving the living conditions and health of the most disadvantaged population strata (Guillaumier et al., 2015). This would be beneficial in terms of ensuring an adequate reduction in smoking rates, while, simultaneously, avoiding an increase in social inequality (Siahpush et al., 2009). ...
... The Australian tobacco taxation policy, based on inflation-adjusted duties, contributed to the lowering of smoking prevalence among low-income individuals. However, it also amplified the inequalities between the lowest and highest socio-economic strata: indeed, in response to the tax increase, many low-income smokers kept smoking by adopting 'price-minimization' strategies, such as cutting back on food or delaying the payment of bills, so as to be able to afford cigarettes (Guillaumier et al., 2015). Similarly, smoking prevalence among the Indigenous population remains very high, in comparison to the non-Indigenous one (Australian Bureau of Statistics, 2017b; Australian Institute of Health and Welfare, 2017). ...
... In Australia, the probability of experiencing smoking-induced deprivation is greater for those from lowincome groups [7,10]. Late bill payments, going without meals and having insufficient money for petrol, clothing and family leisure activities are some of the ways smoking displaces other spending [11]. Experiencing financial stress is more prevalent among smokers than ex-smokers or never smokers [12,13]. ...
... The only previous study that has examined these groups' expenditure longitudinally is from the US using a follow up period of 12 months [16]. Previous studies on expenditure of smokers in Australia by SEP have been based on a national cross-sectional surveys and qualitative interviews that compared them with adults who do not smoke [11,40]. Our GEE model selection approach based on p-value< 0.05 is justified given that a post-hoc analysis showed that based on an average sample size of 2500 per year with compound symmetry correlation structure (corr = 0.5) across annual measure, the models can detect sufficiently small effects (i.e. an standardised effect size of 0.08, equivalent to 8% of SD) with 80% power. ...
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Background: Countries with best practice tobacco control measures have experienced significant reductions in smoking prevalence, but socioeconomic inequalities remain. Spending on tobacco products, particularly by low-income groups can negatively affect expenditure on other goods and services. This study aims to compare the household expenditure of adults who smoke tobacco products and those who formerly smoked across socioeconomic groups. Methods: Daily smokers and ex-smokers were compared using the Household, Income and Labour Dynamics in Australia Survey, over 7 waves. Adults who never smoked were not included. Participants were continuing sample members across waves. Mean number of participants per wave was 2505, 25% were smokers and 75% ex-smokers. The expenditure variables investigated included tobacco products, alcohol, motor vehicle fuel, health practitioners, insurance, education, and meals eaten out. Regression models using the generalized estimating equation technique were employed to compare expenditure data aggregated across the waves by Socioeconomic Index for Areas (SEIFA) quintiles of relative socio-economic advantage/disadvantage while accounting for within-participant autocorrelation. Quintiles are ranked by information such as the income, occupation and access to material and social resources of the residents. Results: Smokers from all quintiles spent significantly less per year on meals out, education and insurance than ex-smokers (p < 0.001). Smokers from quintiles 2-5 spent less on groceries, medicines, and health practitioners (p < 0.01). Smokers from quintiles 1 and 2 (most disadvantaged), spent less on motor vehicle fuel than ex-smokers ($280;95%CI: $126-$434), ($213;95%CI: $82-$344). Smokers from quintiles 2 and 3 spent more on alcohol ($212;95%CI: $86-$339), ($231.8;95%CI: $94-$370) than ex-smokers. Smokers from the least disadvantaged groups spent less on clothing than ex-smokers ($348;95%CI: $476-$221), ($501; 95%CI: $743-$258). Across the whole sample, smokers spent more than ex-smokers on alcohol ($230;95%CI:$95-$365) and less on meals out ($361;95%CI:$216-$379), groceries ($529;95%CI:$277-$781), education ($456;95%CI:$288-$624), medicine ($71;95%CI:$38-$104), health practitioners ($345;95%CI:$245-$444) and insurance ($318;95%CI:$229-$407). Conclusions: Smoking cessation leads to reallocation of spending across all socioeconomic groups, which could have positive impacts on households and their local communities. Less spending on alcohol by ex-smokers across the whole sample could indicate a joint health improvement associated with smoking cessation.
... Low-income smokers may experience stress and anxiety as a result of these insecurities, making tobacco abstinence less of a priority in their lives [3,9,10]. Reasons for financial insecurity may include high unemployment rates and high spending on cigarettes [11,12]. In turn, food insecurity may result if smokers preferentially spend money on tobacco products instead of healthy food and essential items, or if they lack income or the means to obtain food [11,12]. ...
... Reasons for financial insecurity may include high unemployment rates and high spending on cigarettes [11,12]. In turn, food insecurity may result if smokers preferentially spend money on tobacco products instead of healthy food and essential items, or if they lack income or the means to obtain food [11,12]. If tobacco cessation interventions were to take into account some of the complex life issues that low-income smokers encounter, they may be more successful [9]. ...
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Objectives: Smokers with financial and food insecurity may find it difficult to quit smoking and reduce their children's tobacco smoke exposure (TSE). The objective was to examine the associations between child TSE and financial and food insecurity among U.S. school-aged children. Methods: We examined the 2018-2019 National Survey of Children's Health data on 17,484 children 6-11 years old. Children were categorized into TSE groups: (1) No TSE: did not live with a smoker; (2) thirdhand smoke (THS) exposure alone: lived with a smoker who did not smoke inside the home; or (3) secondhand smoke (SHS) and THS exposure: lived with a smoker who smoked inside the home. We conducted weighted logistic, ordinal, and linear regression analyses to assess the relationships between child TSE status and financial and food insecurity, adjusting for covariates. Results: Overall, 13.1% and 1.8% of children had THS exposure alone and SHS and THS exposure, respectively. Compared to children with no TSE, children with THS exposure alone were at 2.17 increased odds (95% CI = 1.83, 2.58, p < 0.001) and children with SHS and THS exposure were at 2.24 increased odds (95% CI = 1.57, 3.19, p < 0.001) of having financial insecurity. Children with THS exposure alone were at 1.92 increased odds (95% CI = 1.58, 2.33, p < 0.001) and children with SHS and THS exposure were at 2.14 increased odds (95% CI = 1.45, 3.16, p < 0.001) of having food insecurity. Conclusions: Children with TSE are at increased risk of experiencing financial and food insecurity. When developing tobacco interventions, a holistic approach to tobacco control that addresses ways to decrease financial and food hardships may improve outcomes.
... Studying Australian responses to tobacco tax, Havard et al. (2018) found that, even though tax increases reduced smoking prevalence among high and low SES smokers equally, taxation fails to exert a stronger impact on this particular population. In response to tax increases, socio-economically disadvantaged smokers often adopt 'price-minimization' strategies to keep smoking (Guillaumier et al., 2015). For example, they buy cheaper products (e.g., roll-your-own tobacco products), share tobacco with their friends, as well as cutting back on food or delaying the payment of bills to afford cigarettes. ...
... Conscious that increased taxation will likely increase attempted illicit activity, higher taxes should be coupled with increased enforcement to prevent trade in illicit tobacco. Similarly, conscious of the equity issues surrounding tobacco taxation, tax increases should be combined with broader policies aimed at improving the living conditions and health of the most disadvantaged strata of the population (Guillaumier et al., 2015). This would be beneficial in terms of reducing smoking rates adequately while avoiding an increase in social inequality (Siahpush et al., 2009). ...
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Since 2010, several nations with impressive histories of smoking cessation have witnessed the proliferation of Alternative Nicotine Delivery Systems (ANDS). Advocates suggest that ANDS offer an effective and safer substitute for combustible tobacco. Critics fear that ANDS could expose consumers to novel harms, discourage smoking cessation and may even renormalize tobacco use. Different nations have adopted radically different regulatory strategies ranging from outright bans to active encouragement of ANDS-led smoking cessation. Economic, social and political factors also influence rates of smoking and uptake of ANDS. An investigation into the national-specific context for smoking cessation; including the role of ANDS in reducing cigarette consumption, is likely of value to regulators around the world hoping to reduce smoking-related morbidity and mortality in their own communities. Five case studies were conducted to review the evidence from Australia, Canada, Japan, South Korea and the UK, drawing on an interdisciplinary framework for investigation combining sociological, ethnographic, policy analytic and econometric disciplinary approaches into a schema for studying the drivers of smoking cessation at the individual, micro, meso and macro levels. Data on smoking, and cessation from four decades was combined with more recent data on ANDS use, to investigate the relationship between tobacco control policies, ANDS use and smoking cessation, as well as other salient aspects of the national tobacco control landscape. Each case study developed specific recommendations for policy makers and the research agenda. This report summarizes the findings of those studies. Taxation and Stop Smoking Services (SSS) were among the most effective cessation drivers. Smoke-free laws were also found to be of value, though the evidence for their efficacy in reducing smoking prevalence is mixed. Other policies that sought to reduce the appeal or opportunity to smoke such as plain pack legislation and health warnings, etc. were less associated with short term reductions in smoking prevalence, though these may yet reduce national smoking rates by discouraging uptake among future generations. Tobacco use continues to be concentrated in socially and economically disadvantaged groups. Where regulations allowed, ANDS (e-cigarettes and heated tobacco in particular) were associated with smoking cessation. Moreover, instances of tobacco use declining even as e-cigarette use increased suggests that e-cigarettes do not necessarily re-normalize tobacco use as feared. The results demonstrate how policy decisions affect ANDS use and the latter’s value as a cessation mechanism. The authors recommend that regulators continue to increase tobacco taxes carefully and study how to integrate ANDS with well-funded SSS provision. Regulators should also seek policies that differentiate among nicotine products with respect to their harms profiles. Future cessation programs should target socially and economically disadvantaged groups where tobacco harms continue to be concentrated. This research highlights the need for high quality open-access data collection and analysis, especially regarding use of ANDS.
... Ceci ne fait qu'augmenter les inégalités sociales de santé existantes. Cet effet d'appauvrissement lié à la taxation a été clairement démontré dans le cas du tabac [98][99][100] . Sixièmement, il n'est pas impossible que certains grands consommateurs issus de populations socio-économiquement plus défavorisées et sous pression financière substituent les boissons sucrées taxées par des aliments sucrés non taxés et moins chers pour maintenir leurs apports en sucre, comme démontré en Hongrie 97 . ...
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... Other studies in Australia have shown that some smokers with a low-middle economy will reduce the household's need and expenditure to maintain smoking on an already limited budget. Most smokers estimate to spend 25%-35% of their income on cigarettes, which often comes at the expense of other important household expenses, such as bills, groceries, clothing, and family activities (Guillaumier et al., 2014). ...
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Smoking is one of the biggest causes of death in the world. The WHO reported that smoking kills 8 million people each year. Besides threatening global health, smoking by rural people tends to detain poverty alleviation efforts due to several factors, including cigarette expenditures and health expenditures. Indonesia has one of the most significant worldwide smoking prevalence and has become one of the countries that most suffer from smoking. The MoH Indonesia reported that health costs due to smoking reached Rp596.61 trillion in 2015. Previous studies found that smoking caused an increase in health expenditure due to smoking-related diseases in Indonesia. However, there is a lack of evidence found in rural areas. This research aims to answer whether smoking affects health expenditure in rural areas. Robust regression analysis is used in this model and processed by STATA 14 application. Using IFLS 5 data, the analysis shows that cigarettes consumed in rural areas have a positive and significant effect on outpatient costs. Increased outpatient costs in rural areas due to smoking will make the rural economy suffer and escalate poverty. The government should intensify the tobacco control policy in rural areas to avoid an increase of poverty rate in Indonesia.
... Due to the nature of our study, we didn't divide participants into various income or occupation groups when we asked them about the effect of cigarette prices on the rate of their cigarette consumption. Therefore, we cannot conclude which income or occupation groups are more sensitive to cigarette price increases; however, existing evidence indicates some socially deprived smokers will reduce essential household spending to maintain smoking on a budget that is already limited [47]. Therefore, even poor smokers may continue buying and using cigarettes by the mechanism explained above. ...
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Background Appropriate increases in tobacco taxes and prices are an essential component of comprehensive tobacco control strategies. This study investigates factors related to the use, sale, and distribution of cigarettes in Iran, focusing on the relationship between cigarette price and its consumption. Methods This interview-based qualitative study was conducted among 20 participants, including cigarette smokers, retail shop owners, large-scale distributors, and an expert in tobacco control research. Results Seven themes were extracted from participant interviews, including the type and price of cigarette, the best time to sell cigarettes, profits from the sale of cigarette, affordability, rise in cigarette price and smokers’ reaction to it, lobbying and black-market sales of cigarettes, and the sale and distribution of cigarettes across the country. Although the price of cigarettes in Iran has shown some increases in the past decade, the timing of these increases are not predictable and the limited amount of these increases has not reduced the use of cigarettes. Following a price increase, consumers are more likely to switch from buying packets to single cigarettes, or buy a less expensive brand, then to quit. Moreover, increases in prices may encourage smokers and sellers to buy a large number of cigarettes and store them for a rainy day. Another adverse effect may be increased smuggling of illicit cigarettes to balance the pressure caused by rising prices. Conclusions Our findings highlight two important aspects concerning cigarette pricing in Iran. First is the change in the type of purchase from the whole box of cigarettes to the single stick cigarette or swapping to less expensive cigarettes. Second, increase in cigarette price (either through taxing or regular increases) could be offset by flooding smuggled cigarettes into the market. Therefore, in addition to raising cigarette prices, reducing cigarette consumption rates in Iran requires the development and effective implementation of regulatory policies to control cigarette smuggling, reduce purchasing, and subsequently curb the use of this leading cause of premature morbidity and mortality.
... 34 Tekanan karena faktor finansial memberikan pengaruh dalam proses berhenti merokok karena secara tidak langsung mengurangi pengeluaran untuk kebutuhan lainnya. [35][36][37][38][39] Berhenti merokok secara langsung atau bertahap merupakan pilihan strategi yang biasa diterapkan oleh setiap perokok dalam berhenti merokok. Strategi berhenti sangat erat kaitannya dengan metode yang digunakan oleh perokok. ...
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Latar Belakang. Tingginya jumlah perokok sebenarnya juga diiringi dengan tingginya keinginan untuk berhenti merokok, namun tidak semua berhasil berhenti merokok.Tujuan. untuk menggali peran motivasi, dukungan sosial, mekanisme coping dalam upaya berhenti merokok.Metode. Penelitian kualitatif dengan rancangan penelitian fenomonologi. Teknik snowball sampling dan rekrutmen via whatsapp digunakan untuk mendapatkan informan, dan dipilih menggunakan purposive sampling. Data dikumpulkan melalui wawancara mendalam kapada 18 orang yang terdiri dari 5 orang (1 perempuan 4 laki-laki) yang sudah berhenti merokok 6 bulan sampai 2 tahun, 4 orang yang sedang berhenti merokok (<6 bulan) dan 9 orang sebagai significant others. Keabsahan data melalui triangulasi, member checking dan peer debrieving. Hasil. Faktor sosial merupakan penyebab yang mendominasi untuk merokok. Motif kesehatan adalah motif utama untuk berhenti merokok. Dukungan untuk berhenti merokok diantaranya dukungan secara emosional dan instrumental.Kesimpulan. Perokok berhenti merokok karena motif kesehatan seperti ingin lebih sehat. Motif non kesehatan diantaranya haram dan pengeluaran membeli rokok lebih banyak dari kebutuhan untuk makan. Coping kognitif seperti mensugesti diri melalui perubahan mindset sebagai salah satu strategi yang dapat dilakukan untuk mengendalikan perilaku merokok. Dukungan sosial hanya sebagai penguat atau moderator. Coping merupakan pengendali utama dalam berhenti merokok. Dukungan sosial sebagai moderator dalam proses berhenti merokok. ABSTRACTIntroduction. A high number of smokers aligned with smoking cessation eagerness, but not all succeed.Objective. to explore the motive, social support and coping mechanism for smoking cessationMethods. Qualitative research with phenomenology research design. We did the snowball sampling technique and participants’ recruitment via WhatsApp and Purposive sampling. 18 in-depth interviews consisted of 5 participants (1 woman and 4 men) who quit smoking within the past 6 months to 2 years, 4 participants who are quitting smoking (<6 months) and 9 people as significant others. Data validation was through triangulation, member checking and peer debriefing.Results. Social factors are the dominant cause of smoking. Health motives are the main motives for quitting smoking. Support for quitting smoking includes emotional and instrumental support Conclusion. Smokers’ motivations to quit due to health reasons such as a better level of health. Non-health reasons are religious prohibition (haram) and cigarette expenses higher than primary (food) expenditure. Research also found cognitive coping such as personal suggestion through mindset change, is one of the strategies to control smoking behavior. Social support as a booster or moderator. Coping is the primary controller in smoking cessation. It’s strengthened by personal willingness. Social support acted a moderator.
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Introduction High rates of tobacco smoking among people who are homeless or living in temporary accommodation exacerbate poor health outcomes and financial disadvantage. There is limited research on this population's perceptions of smoking cessation benefits or support strategies. Methods We conducted a cross‐sectional survey of 68 male smokers living in a temporary accommodation hostel in Brisbane, Australia. The survey measured smoking and quit attempt history, perceptions of cessation aids and benefits of cessation, and awareness of the Intensive Quit Support program—a free Queensland government‐funded program comprising 12 weeks of nicotine replacement therapy supplemented with weekly calls from Quitline. Results Participants (56% aged ≤40 years) spent a high proportion of their income on smoking (median $80/week). Although the most commonly reported perceived benefit of smoking cessation was improved health, more participants were interested in a campaign promoting the financial savings of quitting rather than the health benefits. Twice as many participants reported the high cost of smoking‐provoked thoughts of quitting than graphic health warning labels on cigarette packs (70.6% vs. 30.9%). Participants reported a high level of interest in e‐cigarettes as a cessation aid. There was a low level of awareness but moderate level of interest in the Intensive Quit Support program. Discussion and Conclusions Smoking cessation campaigns promoting the financial savings of cessation may be more salient than health‐focused campaigns among relatively young men who smoke and experience homelessness. There is a clear need for innovative, targeted strategies promoting smoking cessation among this population.
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We updated and expanded a previous systematic literature review examining the impact of tobacco control interventions on socioeconomic inequalities in smoking. We searched the academic literature for reviews and primary research articles published between January 2006 and November 2010 that examined the socioeconomic impact of six tobacco control interventions in adults: that is, price increases, smoke-free policies, advertising bans, mass media campaigns, warning labels, smoking cessation support and community-based programmes combining several interventions. We included English-language articles from countries at an advanced stage of the tobacco epidemic that examined the differential impact of tobacco control interventions by socioeconomic status or the effectiveness of interventions among disadvantaged socioeconomic groups. All articles were appraised by two authors and details recorded using a standardised approach. Data from 77 primary studies and seven reviews were synthesised via narrative review. We found strong evidence that increases in tobacco price have a pro-equity effect on socioeconomic disparities in smoking. Evidence on the equity impact of other interventions is inconclusive, with the exception of non-targeted smoking cessation programmes which have a negative equity impact due to higher quit rates among more advantaged smokers. Increased tobacco price via tax is the intervention with the greatest potential to reduce socioeconomic inequalities in smoking. Other measures studied appear unlikely to reduce inequalities in smoking without specific efforts to reach disadvantaged smokers. There is a need for more research evaluating the equity impact of tobacco control measures, and development of more effective approaches for reducing tobacco use in disadvantaged groups and communities.
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Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
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Introduction: Mental health inpatients smoke at higher rates than general population smokers. However, provision of nicotine-dependence treatment in inpatient settings is low, with barriers to the provision of such care including staff views that patients do not want to quit. This paper reports the findings of a survey of mental health inpatients at a psychiatric hospital in New South Wales, Australia, assessing smoking and quitting motivations and behaviors. Methods: Smokers (n = 97) were surveyed within the inpatient setting using a structured survey tool, incorporating the Fagerström Test for Nicotine Dependence, Reasons for Quitting Scale, Readiness and Motivation to Quit Smoking Questionnaire, and other measures of smoking and quitting behavior. Results: Approximately 47% of smokers reported having made at least one quit attempt within the past 12 months, despite nearly three quarters (71.2%) being classified as in a “precontemplative” stage of change. Multinomial logistic regressions revealed that self-reporting “not enjoying being a smoker” and having made a quit attempt in the last 12 months predicted having advanced beyond a precontemplative stage of change. A high self-reported desire to quit predicted a quit attempt having been made in the last 12 months. Conclusions: The majority of smokers had made several quit attempts, with a large percentage occurring recently, suggesting that the actual quitting behavior should be considered as an important indication of the “desire to quit.” This paper provides further data supporting the assertion that multimodal smoking cessation interventions combining psychosocial and pharmacological support should be provided to psychiatric inpatients who smoke.
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In high-income countries, those with low-to-middle incomes have been observing stagnating median wages and marginal improvements in their living standards. Smokers in financial difficulties appear to be less likely to quit smoking. Understanding the reasons for this is essential to intervening to improve cessation outcomes in this population, and reduce smoking-related health inequalities. We used longitudinal data from Waves 4 to 7 of the ITC Four Country Survey (ITC-4), and included those with data from at least two consecutive waves. Associations between financial difficulties and making a quit attempt, and quit success were analysed using generalised estimating equations, with adjustment for confounders. Mediation analysis was conducted to identify potential mediators of the observed effects of financial difficulties on cessation outcomes. Having financial difficulties had little impact on making quit attempts (adjusted OR 0.84, 95% CI 0.70-1.01). Smokers with financial difficulties were substantially less likely to succeed at quitting (adjusted OR 0.55, 95% CI 0.39-0.76); an effect which was consistent over the survey years. Among the potential mediators examined, those relating to cognition of health-related and quality of life-related consequences of smoking were the most important mediators, though the proportion of the effect mediated by the largest mediator was small (6.8%). Having financial difficulties remains an important barrier to smokers achieving quit success. This effect does not appear to be due to anticipated factors such as reduced use of cessation services or treatment. Further research is required to determine strong mediators of the financial difficulties effect on quit success and to tailor more effective cessation programmes.