Inequalities in the Impact of National Reimbursement of Smoking Cessation Pharmacotherapy and the Influence of Injunctive Norms: An Explorative Study

In 2011, the Dutch government reimbursed smoking cessation pharmacotherapy with behavioral therapy for quitting smokers. We investigate whether inequalities in the use of pharmacotherapy change and, if not, whether this is due to a relatively positive injunctive norm in lower socioeconomic status (SES) groups. A total of 75,415 participants aged ≥15 years from the Dutch Continuous Survey of Smoking Habits, 2009-2012, were considered with the following measures: SES (education/income), injunctive norm (mostly acceptable/neutral/mostly unacceptable), period (2011/all other years), and pharmacotherapy use (yes/no). The proportion of low SES smokers compared with high SES smokers making quit attempts with pharmacotherapy did not differ significantly. The injunctive norm of low SES smokers differed significantly from high SES smokers and nonsmokers of all SES levels. Low income smokers with mostly acceptable injunctive norms were significantly less likely to make quit attempts using pharmacotherapy than those with a neutral or less accepting injunctive norm. The significantly lower use of pharmacotherapy in quit attempts in low income smokers with a positive injunctive norm toward smoking may partly underlie the lack of uptake of reimbursed pharmacotherapy in low SES smokers.