Smoking cessation and financial stress
Mohammad Siahpush, Professor1,
Matt Spittal, Dr2
Gopal K. Singh, Dr3
1 Department of Health Promotion, Social and Behavioral Health Sciences, College of Public Health, University of Nebraska Medical Center, 986075 Nebraska Medical Center, Omaha, NE 68198-6075, USA
2 Centre for Behavioural Research in Cancer, The Cancer Council Victoria, 100 Drummond Street, Carlton 3053, Victoria, Australia
3 Maternal and Child Health Bureau, HRSA, US Department of Health and Human Services, 5600 Fishers Lane, Room 18-41, Rockville, MD 20857, USA
Address correspondence to M. Siahpush, E-mail: msiahpush{at}unmc.edu
Background Research on the financial consequences of quitting smoking is scant. We examined the association of smoking cessation with the subsequent likelihood of experiencing financial stress.
Methods Data came from Waves 1, 2 and 3 (2001–04) of the Household Income and Labour Dynamics in Australia survey. The size of the subsample of smokers in Wave 1 who also participated in Waves 2 and 3 was 1747. We compared respondents who reported to have been a smoker in all three waves with those who were smokers only in Wave 1. Eight questionnaire items were used to construct a binary financial stress indicator.
Results The odds of experiencing financial stress in Wave 3 were 42% (95% CI: 6–74%; P = 0.028) smaller for quitters than for continued smokers.
Conclusions Interventions to encourage smoking cessation among disadvantaged groups are likely to enhance their material conditions and standards of living, and to reduce socio-economic disparities in mortality.
Keywords: Australia, financial stress, smoking cessation
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Introduction |
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Tobacco smoking accounts for 12% of the global adult mortality.1 In Australia it is estimated to kill over 19 000 people each year and is responsible for about 10% of the entire national burden of disease and injury.2 Although health benefits of smoking cessation are well-established,3–5 financial consequences of quitting smoking for individual smokers have never been investigated. However, several studies have examined financial stress and hardship as a predictor of smoking behaviour. A study in the UK using cross-sectional and qualitative data from a sample of working class mothers reported that the major reason for relapse after cessation was difficulty coping with everyday problems and stress, including financial stress.6 The authors concluded that restricted access to material resources (housing conditions, income, employment and living standards) hinders smoking cessation. Another study employed longitudinal data from a sample of lone mothers in the UK and reported that smoking provides an affordable palliative for stress and that financial hardship was the main barrier to quitting. Hardship was referred to as the experience of financial anxiety, being in debt that cannot be paid off easily, and not being able to afford essential consumer items such as food and clothing.7 Similarly, an Australian study used national longitudinal data and reported that smokers with more financial stress (e.g. difficulty in paying electricity, gas or telephone bills, and going without meals due to shortage of money) at baseline were less likely to quit and that ex-smokers with more financial stress at baseline were more likely to relapse.8 We do not know of any published prospective studies that examine how smoking cessation affects subsequent levels of financial stress. Our aim was to use longitudinal data from a representative national sample in Australia to examine the association of smoking cessation with the subsequent likelihood of financial stress.
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Methods |
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We used data from Waves 1 to 3 (2001–04) of the Household Income and Labour Dynamics in Australia (HILDA) survey, a national longitudinal study based on a multi-stage area sample of households. The main focus of HILDA is on household structure, income, economic well-being and employment participation. However, respondents are also asked several questions about health and health-related behaviour. The first wave of the survey was conducted between August 2001 and January 2002, and involved face-to-face interviews with all household members aged 15 and over. Interviews were obtained from 7982 households, representing 66% of all households that were identified as in-scope. This in turn generated a sample of 15 127 people eligible for interview, 13 969 of whom were interviewed. In Wave 2 (between August 2002 and March 2003), 11 993 of respondents from Wave 1, and in Wave 3 (between August 2003 and March 2004), 11 190 of respondents from Wave 2 were successfully interviewed. The survey is described in more detail elsewhere.9 The study was approved by the University of Melbourne Human Research Ethics.
We used data from a sub-sample of 1747 respondents who were aged 18 and over and reported being current smokers in Wave 1, and were either smokers in Waves 2 and Waves 3 (smokers) or were ex-smokers in Waves 2 and 3 (long-term quitters, i.e. quit for about 1 year or longer).10 In Wave 1, respondents were asked: ‘Do you smoke cigarettes or any other tobacco products?’ They were provided with three options: ‘No, I have never smoked’, ‘No, I have given up smoking’ and ‘Yes’, distinguishing never-smokers, ex-smokers and current smokers, respectively. In Waves 2 and 3, respondents were asked the same question on smoking with the following response options: ‘No, I have never smoked’, ‘No, I no longer smoke’, ‘Yes, I smoke daily’, ‘Yes, I smoke at least weekly (but not daily)’ and ‘Yes, I smoke less often than weekly’. The last three options identify current smokers.
Financial stress was measured with the items: ‘[In the past 6 months] did any of the following happen to you because of a shortage of money?... Could not pay electricity, gas or telephone bills on time, ... Could not pay the mortgage or rent on time, ... Pawned or sold something, ... Went without meals, ... Was unable to heat home, ... Asked for financial help from friends or family, ... Asked for help from a welfare/community organization?’ These were binary (yes/no) items. Respondents were also asked whether they could raise, within a week, AU$2000 for an emergency. We created a binary financial stress indicator identifying people who experienced a financially stressful event or could not easily raise emergency money. The above items were previously used by Siahpush et al.11 and Siahpush and Carlin8 to construct a scale that was used as a predictor of smoking behaviour. These items were also employed by La Cava and Simon12 to construct an index of financial stress that was used in an analysis of household debt in Australia.
Education was categorized into three groups: year 12 (final year of high school) or below; trade certificate or diploma; and university degree. Occupation was coded based on the Australian Standard Classification of Occupations13 and divided into: blue-collar, including tradespeople, production and transport workers and labourers; white-collar, including clerical, service and sales workers; and professionals, including managers, administrators, professional and associated professionals. Income was divided into four categories, as shown in the Tables 1, 2 and 3.
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Statistical analyses were performed with Stata 8.214 on cases with complete data for all covariates. We used logistic regression to examine the association of cessation with financial stress measured at Wave 3, adjusting for baseline financial stress and other covariates. The ‘svy’ commands in Stata were used to compute robust standard errors and account for the effects of the complex sample design.
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Results |
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Of the 1747 smokers in Wave 1, 92.2% remained smokers during all three waves. Table 1 shows sample characteristics along with the percentage that have quit and the percentage in financial stress for each socio-demographic group. P-values for the bivariate association of covariates and the outcome are the same as the p-values associated with crude parameter estimates in Table 3. Approximately 63% of smokers and 49% of quitters experienced financial problems in Wave 3. Being a male, being married and having a higher level of education, occupation and family income were associated with a lower probability of financial stress. A notably high percent of respondents from high-income households reported financial stress. This is because 36% of them were unable to raise, within a week, AU$2000 for an emergency. The distribution of items used to create the financial stress index is presented in Table 2.
Table 3 provides crude and adjusted odds ratios for the association of covariates with the probability of experiencing financial stress. After controlling for all covariates, there was evidence that higher age, being a male, being married and higher socio-economic status were associated with financial stress. There was also evidence that smoking cessation was related to a lower probability of financial stress. The odds of experiencing financial stress in Wave 3 were 42% (95% CI: 6–74%; P = 0.028) smaller for quitters than for continued smokers.
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Discussion |
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Main finding of the study
This research used longitudinal data from Australia and showed that the long-term smoking cessation is likely to reduce financial stress.
What is already known on this topic
The findings presented in this article are consistent with the studies of lower SES women described in the introduction.6,7 They are also consistent with two cross-sectional population-based studies of people from a wide range of the socio-economic spectrum. Stronks et al.,15 using a Dutch sample, reported that financial stress (difficulty in payment of bills, food, rent, etc.) was associated with smoking status. Siahpush et al.,11 using Australian data, showed that households reporting tobacco expenditure were more likely to experience financial stress. Due to the cross-sectional nature of these studies, the causal direction between smoking and financial stress could not be ascertained. The design of the present research, however, may imply a causal direction from cessation to a reduced probability of financial stress. Our results, together with findings from a previous prospective study that financial stress may cause lower cessation rates among smokers (and higher probability of relapse among ex-smokers),8 suggest that in all likelihood the relationship between financial stress and smoking is reciprocal. Financial deprivation can impede cessation and smoking contributes to financial disadvantage.
What this study adds
By examining the effect of long-term cessation on financial stress, the study contributes to the growing research on the effect of smoking on social disadvantage and inequality. A recent article based on a survey of a population-based sample from the US, UK, Canada and Australia showed that between one-fifth and one-third of respondents reported to have spent money on cigarettes that they ‘knew would be better spent on household essentials like food’.16 It was also shown that there is a social gradient in this phenomenon, such that lower income smokers are notably more likely to experience ‘smoking-induced deprivation’ than their well to do counterparts.17 Thus, campaigns and interventions to encourage smoking cessation among disadvantaged groups are likely to enhance their material conditions and standards of living.
Given recent findings that smoking substantially contributes to socio-economic differentials in mortality in Australia and elsewhere,17,18 policies that aim to reduce smoking prevalence among disadvantaged groups are not only likely to benefit the health and financial well-being of these groups, but reduce societal level health inequalities. As such, tobacco control strategies targeting these groups can be viewed as social policy. This indicates the usefulness of a partnership between the tobacco control and the social services sector. Such a partnership has recently been initiated by the New South Wales Cancer Council (Australia) with the launch of ‘Lifting the Burden: Tobacco Control and Social Equity Strategy 2006–2011’, to reduce high smoking prevalence among disadvantaged groups. A focus of this rare strategy is to enhance awareness and understanding of smoking risks among social services agencies and to build their capacity to contribute to tobacco control.
Strengths and limitations
A strength of this study is the use of prospective national population data, and as such it adds a unique perspective to an area of research dominated primarily by cross-sectional information. The facts that smoking cessation was measured prospectively using data from Waves 1, 2 and 3, and that financial stress was measured in Wave 3, imply a causal relationship between cessation and financial stress, as explained above. The national and population-based nature of the research design, compared with experimental or intervention studies, provides more confidence in the external validity of the results. The design also afforded the inclusion of many population sub-groups in the sample and as such allowed us to statistically control for major socio-demographic factors.
The study used a self-reported measurement of smoking status, which may have resulted in underreporting of smoking. However, previous research has shown that questionnaire-based surveys of the general population provide a reliable estimate of smoking status when cotinine validated, without systematic differentials in underreporting by socio-economic groups.19,20 The amount of misclassification (proportion of self-reported non-smokers with increased cotinine levels indicative of active smoking) is very low (for example, 0.921 and 1.4%22) in most community-based studies,23 but much higher in clinical trials and intervention studies,23 especially among young adults.24 Under-reporting of smoking is not a major concern in the present study, as our aim was not to provide accurate estimates of smoking prevalence or cessation rates, but to examine the association of smoking cessation and financial well-being.
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M.S. was funded by a fellowship from the Victorian Health Promotion Foundation (VicHealth). The data came from the Household Income and Labour Dynamics in Australia (HILDA) survey, which is funded by the Department of Family and Community Services (FaCS) and conducted by the Melbourne Institute for Economic and Social Research at the University of Melbourne.
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The majority of this research was conducted while the first author was affiliated with the Centre for Behavioural Research in Cancer, the Cancer Council Victoria, Australia. The research findings are the product of the researchers and the views expressed should not be attributed to FaCS or the Melbourne Institute.
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References |
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