Links between disability and smoking

Smoking rates have been falling for decades, but tobacco is still a major cause of illness and premature death – and different groups in society remain persistent smokers. We know this is true for people with ‘functional’ disabilities, by which we mean a condition which limits their ability to perform tasks or activities which are part of daily life. But we don’t know whether disability is linked to taking up smoking, and if so how.

As far as we know, our research is the first to use nationally representative longitudinal data to examine whether adults with functional disabilities are more likely to start smoking than their non-disabled peers.

Using the data

We used data from Wave 10 of Understanding Society (2018-19), with a sample of 20,529 adults who began as non-smokers, 15,368 of them with no functional disability, and 5,161 with a disability. We looked at them again in Wave 14 (2022-23) to see how many had taken up smoking (based on their answer to the question: “Do you smoke cigarettes regularly? Please do not include electronic cigarettes (e-cigarettes).”)

We assessed functional disability using their answers on:

• mobility (moving around at home or walking)
• lifting or carrying objects
• manual dexterity (using hands for everyday tasks)
• continence (bladder or bowel control)
• physical coordination
• personal care
• hearing (apart from using a standard hearing aid)
• sight (apart from wearing standard glasses)
• cognitive functioning (memory, concentration, learning or understanding)
• communication or speech
• recognising physical danger
• other long term health problems or disabilities.

If they reported at least some difficulty in one or more of these areas, we defined this as a functional disability. We also had a secondary measure of those affected in two or more domains, and a third measure of how severely they were affected. We also took age, sex, education, ethnicity, and whether they lived in an urban or rural area into account.

Our baseline

The Wave 10 data gave us our baseline, showing that participants with functional disabilities were older than those without – 52.2% were 60 or over, compared to 28.7% of those without a disability. Women made up a higher proportion of the functionally disabled group (60%) than of the non-disabled group (56.1%).

There was no significant difference between urban and rural dwellers, but there was for education level: 35.9% of participants with a functional disability held a degree or higher qualification compared to 48.3% of those without. Also, 44% of those with a disability reported lower or no qualifications compared to 29.8% of those without.

There was also a small difference by ethnicity, with participants with functional disabilities slightly more likely to identify as White (82.7% vs 80.4%).

Results

By Wave 14, 379 participants who were non-smokers in Wave 10 had started smoking, representing 1.9% of our sample. Of these, 102 had a functional disability (2% of the original 5,161) and 277 did not (1.8% of 15,368).

We modelled relative risks for starting to smoke by functional disability status, and in our unadjusted results, there was no significant link between the two. However, when we adjusted for age and sex, people reporting any functional disability had a 57% higher risk of taking up smoking compared to those without a disability. When we took education, ethnicity, and urban/rural living into account, the link remained strong, but was slightly smaller.

We then looked at how many functional disabilities people had. Those with one showed no significant difference in the risk of starting to smoke than those with none, but people with two or more functional disabilities had a significantly higher risk. Each additional functional disability meant a 31% higher chance of taking up smoking.

Of the 379 participants who reported smoking, we had data on how much they smoked for 324 of them, of whom 48.1% smoked more than 10 cigarettes a day. The proportion of heavy smokers was significantly higher among people with a functional disability (63.7%) compared to those without (42.1%). This level of difference was reduced when we took age, sex, education, ethnicity, and urban/rural living into account, but was still statistically significant. This suggests that functional disability is associated with a higher likelihood of smoking more than 10 cigarettes a day even after accounting for sociodemographic differences.

We also looked at type of disability, and found that participants with mobility difficulties or who had difficulty lifting or carrying objects were substantially more likely to start smoking. However, problems with manual dexterity, continence, hearing, sight, and physical coordination were not.

There were stronger effects for people with issues involving greater dependency or cognitive challenges. Those with personal care difficulties had nearly double the risk of starting to smoke, and people reporting memory, concentration, learning, or understanding impairments were at higher risk, too – as were people with other health problems or disabilities, and those who reported difficulty recognising physical danger. There were no significant links with communication or speech impairments, though.

Findings and implications

Overall, there is clear evidence of a link between functional disability and smoking – and also between some disabilities and smoking more heavily. There are theories which might explain this – for example, that these difficulties combine with environmental and social barriers to shape health behaviour. Pain, fatigue, and restricted access to employment or social activities may encourage smoking as a coping mechanism. Mobility problems might make social isolation worse, making it more difficult for health messages to reach people. Difficulties with personal care or lifting may amplify feelings of dependency or reduced autonomy, which might drive people to smoke to relieve stress.

There are considerable differences between people with disabilities, so it is difficult to generalise – someone who is deafblind will have a very different life to someone with continence and lifting difficulties, for example. Our results highlight a need for health campaigns targeted at specific groups to address specific functional limitations. That could mean accessible digital campaigns, community-based outreach for those with mobility or personal care challenges, and targeted inclusion of disabled voices in developing campaigns. Governments also need to address factors which drive higher smoking rates in disabled populations, such as poverty, social exclusion, and inadequate access to healthcare.

Read the research

Authors

Informing PolicyHealth and wellbeing