The contribution of smoking and obesity to income-related inequalities in health in England

Breastfeeding moderates childhood obesity risk associated with prenatal exposure to excessive gestational weight gain

Gaining excessive gestational weight may increase obesity risk in the offspring, while breastfeeding lowers that risk. Using data from the Special Supplemental Nutrition Programme for Women, Infants and Children (WIC) in Southern California, we examined the associations between gestational weight gain (GWG), breastfeeding during infancy and childhood obesity at 2-4 years, and determined whether breastfeeding moderated the association between GWG and childhood obesity. GWG was based on weight measurements collected during the first trimester and within a month before delivery. GWG values were standardized by gestational age (GWG z-scores), per maternal prepregnancy body mass index (BMI) and categorized into tertiles. Fully breastfeeding duration was determined by WIC infant package data indicating the amount of infant formula received monthly. Children's length (or height) and weight measurements were used to calculate BMI-for-age z-scores and identify obesity (z-score ≥ 95th percentile). Multivariable linear and modified Poisson regression analyses were conducted. Fully breastfeeding moderated the association between GWG z-scores tertile and obesity in the offspring. Each additional month of fully breastfeeding was associated with 3%-5% obesity risk reduction for each age group and GWG z-scores tertile, except at age 4 years for children whose mothers had low GWG z-scores (tertile 1). Shorter fully breastfeeding duration was associated with greater obesity risk among children of mothers with high GWG z-scores (tertile 3), but not for those whose mothers had low GWG z-scores. Longer fully breastfeeding duration may provide greater protection against obesity among children at higher risk due to intrauterine exposure to high gestational weight gain.

Estimating Income-Related Health Inequalities Associated with Tobacco and Alcohol Consumption in Namibia

Disparities in resources and access to material opportunities are important determinants of income-related health inequality. This paper hypothesises that the gradient of the inequality in health between the poor and the rich is likely to depend on differences in lifestyle practices including tobacco use and alcohol abuse. Using the 2015/16 Namibia Household Income and Expenditure Survey and the Erreygers corrected concentration index, we estimate the effect of tobacco and alcohol use on income-related health inequalities. A decomposition technique was used to estimate the separate and joint contribution of tobacco and alcohol use to income-related health inequalities. The results indicate that tobacco use widens the income-related health inequality gap while alcohol consumption reduces health disparities. The simultaneous consumption of these goods has a stronger multiplicative effect on income-related health inequality. For instance, the simultaneous consumption of both goods contribute up to 1.03% of the inequality in health while tobacco use alone contributed only 0.6%. While policy options for each of these goods could be essential in reducing inequalities in health, there is a need to advocate additional measures that could simultaneously control the consumption of both goods.

Estimating the Health Effect of Cigarette Smoking Duration in South Africa

This paper deepens the empirical analysis of the health effects of smoking by using the average treatment effect on the treated (ATET) and regression discontinuity design (RDD) to estimate the impact of smoking duration on health. The paper estimates the effect of cigarette smoking on health, that is, the exogenous increase in the probability of smoking-related ill health when individuals smoke up to a certain number of years. Using the National Income Dynamic survey (NIDS), the study finds that the probability of reporting poor health and/or suffering smoking-related diseases increases with the years of smoking. The magnitude of the effect is higher when smoking-related diseases rather than self-assessed health is considered but varies across time, socioeconomic status, and with different health outcomes. The effects are robust under several different parametric and non-parametric models. Using RDD, the paper also finds evidence of a discrete jump in poor health when individuals smoke up to 30 years. The results suggest that policies that are designed to reduce current levels of cigarette smoking may have a desirable impact and can create both current and future public health benefits.

Comprehensive metrological and content analysis of the income inequality research in health field: A bibliometric analysis

The association between income inequality in a society and the poor health status of its people has attracted the attention of researchers from multiple disciplines. Based on the ISI Web of Science database, bibliometric methods were used to analyze 546 articles related to income inequality research in health field published between 1997 and 2021. We found that the USA contributed most articles, the Harvard Univ was the most influential institution, Social Science & Medicine was the most influential journal, and Kawachi I was the most influential author; the main hotspots included the income inequality, income, health inequality, mortality, socioeconomic factors, concentration index, social capital, self-rated health, income distribution, infant mortality, and population health in 1997-2021; the cardiovascular disease risk factor, social capital income inequality, individual mortality risk, income-related inequalities, understanding income inequalities, income inequality household income, and state income inequality had been the hot research topics in 1997-2003; the self-assessed health, achieving equity, income-related inequalities, oral health, mental health, European panel, occupational class, and cardiovascular diseases had been the hot research topics in 2004-2011; the adolescent emotional problem, South Africa, avoidable mortality, rising inequalities, results from world health survey, working-age adult, spatial aggregation change, prospective study, and mental health-empirical evidence had been the hot research topics in 2012-2021; there were 11 articles with strong transformation potential during 2012-2021. The research results of this paper are helpful to the scientific understanding of the current status of income inequality research in health field.

Socioeconomic status and tobacco consumption: Analyzing inequalities in China, Ghana, India, Mexico, the Russian Federation and South Africa

INTRODUCTION

Globally, there has been a rapid rise in non-communicable diseases driven by changing lifestyle choices and health behaviors. Different lifestyle choices threaten to exacerbate existing health inequalities, yet evidence monitoring the extent of this impact in emerging economies is lacking. The article sets out to measure the level of wealth-related inequality and its drivers in one of these lifestyle choices, tobacco consumption, among populations aged ≥50 years in six Low- and Middle-Income Countries.

METHODS

The study provides empirical evidence of the inequality in tobacco consumption across wealth groups in China, Ghana, India, Mexico, the Russian Federation and South Africa using the Erreygers’ corrected concentration indices. These inequalities are then decomposed to gain a deeper understanding of the factors and broader social forces driving inequality. The WHO SAGE data set, collected between 2008 and 2010, is used for the analysis.

RESULTS

Current tobacco consumption is concentrated among the poor in China, Ghana, India, and South Africa, and among the wealthy in the Russian Federation and Mexico. The inequalities widen when we focus solely on the male population. Although the results differ by country, the major drivers of inequality include wealth, locality, and gender.

CONCLUSIONS

The focus on tobacco consumption in this age group is key to curbing rising healthcare costs and ensuring longevity. Policies aimed at reducing wealth-related inequalities should especially target high tobacco consumption rates among males, while simultaneously pre-empting and curbing rising rates among women.

Socioeconomic inequality in noncommunicable diseases: Results from a baseline Persian cohort study

Background: Contrary to health indices advancement during recent years, health inequalities are still a global challenge. This study aimed to determine socioeconomic factors for noncommunicable diseases using concentration indices (CI).

Methods: This cross-sectional study was conducted on the baseline data from a cohort study in Fasa (southern Iran). Principle component analysis was used to measure asset index. Moreover, socioeconomic inequalities were calculated by CI. Analysis was done at 95% confidence level using STATA software.

Results: A total of 7990 individuals were included in the study. The highest negative CIs were significantly found for epilepsy (-0.334), paramnesia (-0.255), and learning disabilities (-0.063), respectively, and the lowest were significantly found for chronic headaches (-0.046), recurrent headaches (-0.03), infertility (-0.028) and hypertension (-0.057). This index was positive for breast cancer (0.298). Furthermore, it was not Significant for diabetes, thyroid disorders, depression, and chronic lung diseases.

Conclusion: The findings showed a significant inequality in the most of the noncommunicable diseases in the region, which are more concentrated among the poorest population. Policymakers in the health system and city planners should consider these results to decrease the burden of noncommunicable diseases in the society by identifying vulnerable subcategories.

Biomarkers, disability and health care demand

Using longitudinal data from a representative UK panel, we focus on a group of apparently healthy individuals with no history of disability or major chronic health condition at baseline. A latent variable structural equation model is used to analyse the predictive role of latent baseline biological health, indicated by a rich set of biomarkers, and other personal characteristics, in determining the individual's disability state and health service utilisation five years later. We find that baseline biological health affects future health service utilisation very strongly, via progression to functional disability channel. We also find systematic income gradients in future disability risks, with those of higher income experiencing a lower progress to disability. Our model reveals that observed pro-rich inequity in health care utilisation, is driven by the fact that higher-income people tend to make greater use of health care treatment, for any given biological health and disability status; this is despite the lower average need for treatment shown by the negative association of income with both baseline ill biological health and disability progression risk. Factor loadings for latent baseline health show that a broader set of blood-based biomarkers, rather than the current focus mainly on blood pressure, cholesterol and adiposity, may need to be considered for public health screening programs.

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology

BACKGROUND

In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality.

METHODS

Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII.

FINDINGS

Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere.

CONCLUSIONS

Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Lifestyle and socio-economic inequalities in diabetes prevalence in South Africa: A decomposition analysis

BACKGROUND

Inequalities in diabetes are widespread and are exacerbated by differences in lifestyle. Many studies that have estimated inequalities in diabetes make use of self-reported diabetes which is often biased by differences in access to health care and diabetes awareness. This study adds to this literature by making use of a more objective standardised measure of diabetes in South Africa. The study estimates socio-economic inequalities in undiagnosed diabetes, diagnosed diabetes (self-reported), as well as total diabetes (undiagnosed diabetics + diagnosed diabetics). The study also examines the contribution of lifestyle factors to diabetes inequalities in South Africa.

METHODS

This cross sectional study uses data from the 2012 South African National Health and Nutrition Examination Survey (SANHANES-1) and applies the Erreygers Concentration Indices to assess socio-economic inequalities in diabetes. Contributions of lifestyle factors to inequalities in diabetes are assessed using a decomposition method.

RESULTS

Self-reported diabetes and total diabetes (undiagnosed diabetics + diagnosed diabetics) were significantly concentrated amongst the rich (CI = 0.0746; p < 0.05 and CI = 0.0859; p < 0.05). The concentration index for undiagnosed diabetes was insignificant but pro-poor. The decomposition showed that lifestyle factors contributed 22% and 35% to socioeconomic inequalities in self-reported and total diabetes, respectively.

CONCLUSION

Diabetes in South Africa is more concentrated amongst higher socio-economic groups when measured using self-reported diabetes or clinical data. Our findings also show that the extent of inequality is worse in the total diabetes outcome (undiagnosed diabetics + diagnosed diabetics) when compared to the self-reported diabetes outcome. Although in comparison to other determinants, the contribution of lifestyle factors was modest, these contributions are important in the development of policies that address socio-economic inequalities in the prevalence of diabetes.

Socioeconomic differences in body mass index in Spain: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

Many studies have demonstrated the existence of simple, unidimensional socioeconomic gradients in body mass index (BMI). However, in the present paper we move beyond such traditional analyses by simultaneously considering multiple demographic and socioeconomic dimensions. Using the Spanish National Health Survey 2011–2012, we apply intersectionality theory and multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) to analyze 14,190 adults nested within 108 intersectional strata defined by combining categories of gender, age, income, educational achievement and living situation. We develop two multilevel models to obtain information on stratum-specific BMI averages and the degree of clustering of BMI within strata expressed by the intra-class correlation coefficient (ICC). The first model is a simple variance components analysis that provides a detailed mapping of the BMI disparities in the population and measures the accuracy of stratum membership to predict individual BMI. The second model includes the variables used to define the intersectional strata as a way to identify stratum-specific interactions. The first model suggests moderate but meaningful clustering of individual BMI within the intersectional strata (ICC = 12.4%). Compared with the population average (BMI = 26.07 Kg/m2), the stratum of cohabiting 18-35-year-old females with medium income and high education presents the lowest BMI (-3.7 Kg/m2), while cohabiting 36-64-year-old females with low income and low education show the highest BMI (+2.6 Kg/m2). In the second model, the ICC falls to 1.9%, suggesting the existence of only very small stratum specific interaction effects. We confirm the existence of a socioeconomic gradient in BMI. Compared with traditional analyses, the intersectional MAIHDA approach provides a better mapping of socioeconomic and demographic inequalities in BMI. Because of the moderate clustering, public health policies aiming to reduce BMI in Spain should not solely focus on the intersectional strata with the highest BMI, but should also consider whole population polices.

Limited contribution of health behaviours to expanding income-related chronic disease disparities based on a nationwide cross-sectional study in China

This study estimated the association of income and prevalence of cardiovascular diseases (CVD) and hypertension, and then quantified the contribution of health behaviors to the association in China. Using the 2013 survey of the China Health and Retirement Longitudinal Study (CHARLS), a logit model was applied to examine income-related health disparities in relation to CVD and hypertension. A four-step regression method was then constructed to measure the role of health behaviors in income-related health disparities. Using indirect effects, mediation by health behaviors was examined. Income-related health disparities in chronic diseases were found to exist in China. Specifically, individuals in the high-income group had a 14% (OR = 0.86; 95% CI 0.73-1.02) and 14% (OR = 0.86; 95% CI 0.76-0.97) lower odds of suffering from CVD and hypertension than those in the low-income group. However, limited evidence shows this association was mediated by health behaviors. The Heaviness of Smoking Index (HSI), heavy drinking, irregular eating, and nap time did not significantly mediate the association of income and prevalence of CVD and hypertension. To curb the rising prevalence of CVD and hypertension in China, policies should focus on the low-income subpopulation. However, healthy behaviors interventions targeting smoking, heavy drinking, unhealthy napping and irregular eating habits among low-income people may be ineffective in reduction of income-related disparities in prevalence of CVD and hypertension.

Lifestyle and Income-related Inequality in Health in South Africa

Background

Many low- and middle-income countries are experiencing an epidemiological transition from communicable to non-communicable diseases. This has negative consequences for their human capital development, and imposes a growing economic burden on their societies. While the prevalence of such diseases varies with socioeconomic status, the inequalities can be exacerbated by adopted lifestyles of individuals. Evidence suggests that lifestyle factors may explain the income-related inequality in self-reported health. Self-reported health is a subjective evaluation of people’s general health status rather than an objective measure of lifestyle-related ill-health.

Method

The objective of this paper is to expand the literature by examining the contribution of smoking and alcohol consumption to health inequalities, incorporating more objective measures of health, that are directly associated with these lifestyle practices. We used the National Income Dynamic Study panel data for South Africa. The corrected concentration index is used to measure inequalities in health outcomes. We use a decomposition technique to identify the contribution of smoking and alcohol use to inequalities in health.

Results

We find significant smoking-related and income-related inequalities in both self-reported and lifestyle-related ill-health. The results suggest that smoking and alcohol use contribute positively to income-related inequality in health. Smoking participation accounts for up to 7.35% of all measured inequality in health and 3.11% of the inequality in self-reported health. The estimates are generally higher for all measured inequality in health (up to 14.67%) when smoking duration is considered. Alcohol consumption accounts for 27.83% of all measured inequality in health and 3.63% of the inequality in self-reported health.

Conclusion

This study provides evidence that inequalities in both self-reported and lifestyle-related ill-health are highly prevalent within smokers and the poor. These inequalities need to be explicitly addressed in future programme planning to reduce health inequalities in South Africa. We suggest that policies that can influence poor individuals to reduce tobacco consumption and harmful alcohol use will improve their health and reduce health inequalities.

Retirement and perceived social inferiority strongly link with health inequalities in older age: decomposition of a concentration index of poor health based on Polish cross-sectional data

Background

Identifying mechanisms that generate and sustain health inequalities is a prerequisite for developing effective policy response, but little is known about factors contributing to health inequalities in older populations in post-transitional European countries such as Poland. Demographic aging of all populations requires new and deeper insights.

Methods

Data came from the Polish edition of the cross-sectional European Social Survey, Wave 6 (2012). Logistic regression was applied to identify socioeconomic factors relevant to self-assessed health in a population aged 45 or over. Decomposition of a concentration index provided information about the distribution of health-relevant demographics and social characteristics along a socioeconomic continuum, and their contributions to observed health inequalities.

Results

Overall, 17.4 % of respondents aged 45 or over assessed their health as poor or very poor. Predictors of poor health included income insufficiency, disability or retirement, retirement, low social activity, and social position. A steep socioeconomic gradient in self-assessed health in Polish population was found. The primary contributor to the observed health inequality (as summarized by concentration index) was income, followed by labor market situation, particularly retirement. Self-assessed place in society contributed to overall inequality, scoring similarly to social activity. Contributions from age and education were moderate but non-significant, gender was negligible, and chronological aging explained neither poor health nor socioeconomic health inequalities.

Conclusions

Although elderly people represent a particularly vulnerable group, their disadvantages are associated with social rather than natural causes. Policies addressing health inequalities in aging populations must provide systemic opportunities for maintaining good health. Transitioning to retirement is a critical entry point for policy action that stimulates social engagement and maintains self-esteem of older people.

A discrete latent factor model for smoking, cancer and mortality

This paper investigates the relationship between smoking and ill-health, with a focus on the onset of cancer. A discrete latent factor model for smoking and health outcomes, allowing for these to be commonly affected by unobserved factors, is jointly estimated, using the British Health and Lifestyle Survey (HALS) dataset. Post-estimation predictions suggest the reduction in time-to-cancer to be 5.7 years for those with an exposure of 30 pack-years, compared to never-smokers. Estimation of posterior probabilities for class membership shows that individuals in certain classes exhibit similar observables but highly divergent health outcomes, suggesting that unobserved factors influence outcomes. The use of a joint model changes the results substantially. The results show that failure to account for unobserved heterogeneity leads to differences in survival times between those with different smoking exposures to be overestimated by more than 50% (males, with 30 pack-years of exposure).

Decomposing socio-economic inequality in colorectal cancer screening uptake in England

Colorectal cancer (CRC) is the second largest cause of cancer death in the UK. Since 2010, CRC screening based on Faecal Occult Blood testing has been offered by the NHS in England biennially to all persons age 60-69 years. Several studies have demonstrated a gradient in uptake using area-level markers of socio-economic status (SES), but few have examined the individual-level contributors to the gradient. We aimed to quantify the extent of SES inequality in CRC screening uptake in England using individual-level data, and to identify individual factors associated with this inequality. We used data from 1833 participants (aged 61-69) in Wave 5 (collected in years 2010/11) of the English Longitudinal Study of Ageing (ELSA) eligible for having been sent at least one CRC screening invitation. Uptake was defined by self-report of ever having been screened as part of the National Screening Programme. We assessed socio-economic inequality using the corrected concentration index of uptake against SES rank, which was derived by regressing a range of SES markers against net non-pension household wealth. Other demographic and health-related variables were included in the analysis. Factors associated with inequality were measured using concentration index decomposition. There was a significant pro-rich gradient in screening uptake (concentration index: 0.16, 95% CI:0.11-0.22), mostly explained within our model by differences in non-pension wealth (38.7%), partner screening status (15.9%), sickness/disability (13.5%), and health literacy (8.5%). Interventions aimed at reducing inequalities in CRC screening uptake should focus on improving acceptability of screening in populations with low levels of education and literacy barriers.

Health-income inequality: the effects of the Icelandic economic collapse

Introduction

Health-income inequality has been the focus of many studies. The relationship between economic conditions and health has also been widely studied. However, not much is known about how changes in aggregate economic conditions relate to health-income inequality. Nevertheless, such knowledge would have both scientific and practical value as substantial public expenditures are used to decrease such inequalities and opportunities to do so may differ over the business cycle. For this reason we examine the effect of the Icelandic economic collapse in 2008 on health-income inequality.

Methods

The data used come from a health and lifestyle survey carried out by the Public Health Institute of Iceland in 2007 and 2009. A stratified random sample of 9,807 individuals 18–79 years old received questionnaires and a total of 42.1% answered in both years. As measures of health-income inequality, health-income concentration indices are calculated and decomposed into individual-level determinants. Self-assessed health is used as the health measure in the analyses, but three different measures of income are used: individual income, household income, and equivalized household income.

Results

In both years there is evidence of health-income inequality favoring the better off. However, changes are apparent between years. For males health-income inequality increases after the crisis while it remains fairly stable for females or slightly decreases. The decomposition analyses show that income itself and disability constitute the most substantial determinants of inequality. The largest increases in contributions between years for males come from being a student, having low education and being obese, as well as age and income but those changes are sensitive to the income measure used.

Conclusions

Changes in health and income over the business cycle can differ across socioeconomic strata, resulting in cyclicality of income-related health distributions. As substantial fiscal expenditures go to limiting the relationship between income and health, the business-cycle effect on equality, which has up until now not received much attention, needs to be considered.

Determinants of changes in income-related health inequalities among working-age adults in Japan, 1986-2007: time-trend study

This study aimed to quantify the contributions of the factors that have influenced changes in income-related health inequalities. We used data from a nationally representative sample of Japanese men and women aged 20-59 years who participated in eight repeated cross-sectional surveys between 1986 and 2007. A concentration index (CI) was used to measure income-related inequalities in self-rated health (SRH) and decomposed into contributing factors. We then examined temporal changes in CIs and their contributing factors. Results showed that income-related inequalities in SRH, unfavourable to low-income groups, persisted throughout the study period. Despite widening income inequalities, inequalities in SRH narrowed during the period of economic stagnation since the late 1990s because of the profound deterioration in SRH among middle- to high-income groups. Decomposition analysis showed that income itself and unemployment or economic inactivity were the most important contributors to inequalities in SRH for both sexes at almost all time points. However, from 1986 to 2007, the relative contribution of income to these inequalities decreased from 78% to 14% in men and from 85% to 38% in women. By contrast, the relative contribution of unemployment or economic inactivity increased from 18% to 77% in men and from 10% to 31% in women. Our results suggest that a reduction in avoidable health inequalities could be achieved by reducing the influence of unemployment or economic inactivity on health.

A longitudinal study on the impact of income change and poverty on smoking cessation

OBJECTIVES

Research on the association between income and smoking cessation has examined income as a static phenomenon, either cross-sectionally or as a predictor variable in longitudinal studies. This study recognizes income as a dynamic entity and examines the relationship between a change in income and subsequent smoking behaviour.

METHOD

Longitudinal data from the National Population Health Survey (1994/5 to 2008/9) were used to examine the impact of (1) change in income and (2) change in poverty status, on the probability of being a former or current smoker among a sample of Canadians identified as having ever smoked. Covariates include socio-demographic characteristics, number of cigarettes smoked per day, and smoking in the home.

RESULTS

Smoking behaviour was not associated with a change in household income but was associated with a change in household income that moved an individual across the poverty threshold. Canadians whose income increased to above the poverty threshold were less likely to continue smoking than someone who remained in poverty (OR = 0.72, 95% CI: 0.62-0.84). Those who remained out of poverty were also less likely to continue smoking than someone who remained in poverty (OR = 0.66, 95% CI: 0.57-0.75). There was no significant difference between those who remained in poverty and those whose income decreased to below the poverty level.

CONCLUSION

This study strengthens the link between smoking and poverty and supports strategies that address income as a socio-economic determinant of health. Policies that increase household incomes above the poverty line may lead to improvements in smoking cessation rates.