France: Faced with inequalities in tobacco use, a study calls for increased support for the most vulnerable.

Between 2000 and 2021, the prevalence of daily smoking decreased overall in France, but disparities between social classes initially widened before stabilizing and then rising again during the Covid-19 crisis. The study, based on Public Health France's barometers, shows that anti-smoking measures have had real effects, but these effects vary depending on education level, income, and employment status.[1], warning of the need to provide more support for guidance, treatment and professional support for disadvantaged smokers.

A study analyzing over twenty years of smoking in France: objectives, methods and definitions

This study aims to describe the evolution of social inequalities related to tobacco use in France since the early 2000s, taking into account the anti-smoking policies implemented over time. The authors seek to understand whether the major public measures adopted since this period have succeeded in reducing smoking rates across the population as a whole, and also in narrowing the gaps between social groups. This is a crucial issue, as tobacco remains the leading cause of premature and preventable death in France, and it disproportionately affects certain population groups.

The study is based on a secondary analysis of the Public Health France Barometers, a series of cross-sectional telephone surveys conducted regularly between 2000 and 2021. The authors selected the waves of 2000, 2005, 2010, and 2014, followed by the annual surveys from 2016 to 2021, for a total of ten surveys. The cumulative sample comprises 176,261 individuals aged 18 to 75, living in ordinary households in metropolitan France and speaking French. The sampling method combines randomly generated landline and mobile phone numbers, with different selection procedures depending on the type of telephone. The results were weighted to correct for inclusion probabilities and restore the population structure according to several variables: sex, age, region, size of urban area, household size, and education level. This approach makes it possible to produce estimates representative of the adult population of metropolitan France, within the limitations of a self-reported survey.

Daily smoking was defined using three successive questions about tobacco use, frequency of consumption, and average quantity smoked. Respondents were classified as daily smokers if they reported smoking every day or consuming a certain amount of tobacco daily, whether manufactured cigarettes, rolling tobacco, cigars, cigarillos, or shisha. This definition distinguishes regular from occasional smokers, allowing for better monitoring of changes in smoking behavior. The social variables examined were education level, household income, and employment status. Education level was divided into three groups: below or without a high school diploma, high school diploma, and higher than a high school diploma. Income was calculated per consumption unit and divided into tertiles, while employment status distinguished between employed, unemployed, and students or those not in the labor force.

Changes in smoking prevalence reflect socio-economic inequalities

Over the entire study period, the prevalence of daily smoking among 18-75 year olds decreased from 30 % in 2000 to 25.3 % in 2021, with a low of 24 % in 2019. However, this trend was not linear. The authors distinguish three phases: relative stability between 2000 and 2016 at around 30 %, a sharp decline between 2016 and 2019, and then stagnation, or even a slight increase, between 2019 and 2021.

The differences according to education level are particularly pronounced. Among those with the lowest levels of education, the prevalence of daily smoking increased between 2000 and 2016, then declined with the general decrease observed between 2016 and 2019, before rising again between 2019 and 2021. Conversely, among those with the highest levels of education, prevalence decreased during the first part of the period, then stabilized at a lower level. At the beginning of the period, the gap between the groups was already present; it became more pronounced over the years.

Income follows a similar pattern. The lowest-income group saw an increase in smoking prevalence between 2000 and 2016, while it decreased among the wealthiest households. Between 2016 and 2019, all groups experienced a decline, but the decrease once again benefited the most affluent categories. Between 2019 and 2021, the increase resumed, primarily among middle-income households and, to a lesser extent, among the poorest.

Employment status also reveals a clear social gradient. Unemployed individuals have the highest levels of daily smoking, and their smoking patterns are worse than those of employed individuals. Students and the inactive occupy an intermediate position, with lower levels than the unemployed but often higher than those in employment. Here again, the decline recorded between 2016 and 2019 does not erase the structural differences between groups.

Anti-smoking measures, while effective, must be more specifically targeted at the most disadvantaged.

The authors link the first phase, between 2000 and 2016, to a gradual increase in anti-smoking policies, but within a framework where the issue of social inequality was still relatively unimportant. Several measures were nevertheless implemented: price increases, bans on sales to minors, bans on smoking in public places, and health warnings on cigarette packs. According to the study, these measures were adopted more quickly by the most privileged groups, which partly explains the faster decline in smoking rates among these groups. Disadvantaged populations, on the other hand, seem to have reacted more slowly to prevention messages. The authors offer several explanations: less sensitivity to campaigns, a stronger integration of tobacco use into stress management routines, greater difficulty in planning ahead, and different economic trade-offs in the face of rising prices. In this context, some smokers may have turned to cheaper products, such as rolling tobacco, rather than quitting smoking altogether.

The second phase, between 2016 and 2019, appears to be the most favorable. It corresponds to the implementation of the first national tobacco control plans, with a series of combined measures: the "Month Without Tobacco" campaign, plain packaging, improved access to nicotine replacement therapies, and a significant price increase. The authors believe that this combination was generally effective and that it also limited, at least temporarily, the widening of social inequalities. Public policy then took greater account of the disparities between social groups, particularly through communication and support programs more specifically targeted at vulnerable populations.

The third phase, between 2019 and 2021, is more complex. The Covid-19 pandemic hit the most vulnerable populations hardest, economically, socially, and psychologically. In this context, tobacco may have been used more frequently as a tool for managing stress or coping with daily difficulties. The authors also note that tobacconists remained open during lockdowns and that rumors circulated about a possible protective effect of nicotine, which may have obscured the prevention message. At the same time, prevention campaigns lost visibility, and price increases were more limited.

Furthermore, the study places the French results within a European and international context. In several countries where overall tobacco consumption has decreased significantly, differences in consumption linked to social inequalities have remained high, or even worsened. The authors specifically cite the United Kingdom, the United States, Belgium, Spain, the Netherlands, Germany, and Italy, where significant disparities persist based on education level, income, and social status.

This comparison suggests that the average decline in smoking rates does not automatically lead to a reduction in inequalities in consumption between different socioeconomic groups. The most effective measures are often those that initially target the most advantaged groups, who are more receptive to health information, more inclined to use cessation aids, and more likely to convert an intention to quit into lasting abstinence. The study thus highlights a central point: the fight against smoking must explicitly integrate the social dimension. An effective policy must not simply aim to lower average figures but must also ensure that health improvements benefit disadvantaged social classes. The authors therefore emphasize the need to provide more support to disadvantaged smokers to help them move from attempting to quit to achieving lasting abstinence, by combining behavioral support, reimbursed pharmacological treatments, and free remote assistance, with increased support from healthcare professionals to improve the chances of successful smoking cessation, inspired by the positive results achieved in France between 2016 and 2019.

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[1]Pasquereau A., Guignard R., Andler R., Beck F., Nguyen-Thanh V., Smoking and social inequalities in France, 20 years of evolution: A secondary dataset analysis of health barometers,Tobacco Induced Diseases, published June 8, 2026, accessed June 9, 2026

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