Tobacco use is a leading contributor to socioeconomic health disparities in the United States.1–5
Americans with household incomes of $15000 or less smoke at nearly 3 times the rate of those with incomes of $50000 or greater.6
Quit attempts show no socioeconomic gradient, but successful cessation is associated with a considerable socioeconomic disparity7–15
that appears to be increasing.4,16,17
Community-based tobacco dependence treatment programs can reduce these disparities by providing all smokers with needed assistance; however, smokers of lower socioeconomic status (SES) often have poorer treatment outcomes.18–23
Examination of factors related to socioeconomic disparities in treatment outcomes may identify targets for enhancing therapeutic approaches for lower-socioeconomic groups.
In health research, SES is a broad construct describing relative access to basic resources required to achieve and maintain good health.24,25
Common measures of SES (e.g., educational achievement, income, occupation, wealth) assess different, albeit related aspects of the construct but are generally limited by a lack of precision and difficulty classifying all groups. Educational achievement is considered a basic element of SES, captures important aspects of lifestyle and behavior, and is perhaps the most widely used proxy for SES because of its influence on future occupational opportunities and earning potential; however, household income is considered the best measure of available material resources, especially for those who are not primary wage earners in families.24,26,27
Composite measures incorporate and, therefore, adjust for different aspects of SES.28
In the United States, minority ethnic status often affects access to basic resources, but the magnitude of socioeconomic disparities is often greater than that between minority and majority ethnic groups in the United States, and the effects of minority ethnic status on smoking cessation are often reduced or eliminated after socioeconomic factors are taken into account.29–31
Nonetheless, in the United States, ethnic groups tend to live in different social and physical environments, and minority ethnic status often includes a constellation of stressors separate from and additive to SES.29
Moreover, lower SES coupled with tobacco use and minority ethnic status might lead to a unique set of multiple and cumulative disparities.29
Conceptual models propose that health disparities emerge because of higher levels of stress, less access to physical and environmental resources, greater environmental constraints, fewer affective and cognitive resources, and poorer health behaviors.26,32
Consistent with these models, SES is empirically related to smoking cessation through complex reciprocal relations among numerous clinical and environmental factors, including stress, coping resources, psychological factors, exposure to other smokers, and use of treatment resources.33–38
Cognitive-behavioral treatment of tobacco dependence can potentially address many of these factors, but little is known about the role these factors play when lower-SES smokers are provided with treatment.
Disparities are prominent among numerous factors important to cessation and treatment of tobacco dependence. In the United States, minority ethnic groups such as African Americans and Hispanic Americans as well as lower-SES groups are less likely to receive advice about and assistance with smoking cessation from health care providers.39–41
Although minority ethnic groups are no less likely to quit when provided with nicotine replacement,42
they and lower-SES groups are less likely to have accurate information about nicotine replacement and less likely to use evidence-based tobacco dependence treatments.43–47
Lower-SES groups are less likely to be covered by smoking bans in the workplace and at home,48–50
and some lower-SES groups are more highly nicotine dependent than higher-SES groups.51
The role of many of these disparities in the treatment of tobacco dependence remains relatively unexamined.
We examined socioeconomic disparities in a community-based tobacco dependence treatment program in Arkansas. We used statistical modeling of treatment outcomes to examine the independent contributions of SES, ethnicity, and other factors. Consistent with conceptual models and previous studies, we hypothesized that the lowest-SES participants would have less treatment use and the greatest clinical and environmental challenges to achieving and maintaining abstinence from tobacco use.