Decomposition of socioeconomic inequalities in smoking status in Indonesia: a decade of widening gaps

<h2>ABSTRACT</h2><h3>Background</h3> Tobacco consumption persists as a significant global health issue. In Indonesia, smoking rates have changed little despite various policies, potentially due to underlying socioeconomic disparities. This study provides the first comparative assessment of socioeconomic inequalities in smoking behavior in Indonesia over ten years. <h3>Objective</h3> To quantify socioeconomic inequality in smoking status in Indonesia and determine the contribution of different factors to this inequality. <h3>Methods</h3> We utilized two nationally representative surveys from Indonesia, conducted in 2013 (Basic Health Research) and 2023 (Indonesia Health Survey). The sample was individuals aged >15 years. Socioeconomic inequality was measured using the concentration curve and the Wagstaff-normalized concentration index. We applied concentration index decomposition to determine the relative contributions of demographic, socioeconomic, and health-related factors. <h3>Results</h3> The concentration indices for smoking were -0.060 (p<0.001) in 2013 and -0.089 (p<0.001) in 2023, indicating a pro-poor concentration of smoking that widened over time. The decomposition analysis revealed that household socioeconomic status and education level were key factors explaining the pro-poor inequalities in smoking status in Indonesia in both 2013 and 2023. Additionally, occupation type contributed to the inequality in 2013, while insurance ownership emerged as a contributing factor in 2023. <h3>Conclusion</h3> There is an increase in socioeconomic inequalities in smoking behavior in Indonesia from 2013 to 2023. Tobacco control efforts should prioritize equity by enhancing health education, expanding culturally tailored cessation support, adopting innovative motivation tools to support quitting, and integrating cessation services into the national health insurance system.