Theory

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Defining low-SES
SES comprises economic, social and work status that are commonly measured by three indicators,
education, income and occupation. Low-SES is highly diverse in cultures, ethnicities and social and
economic statuses
General introduction
Smoking is the leading cause of preventable disease and death. SES (education, income and
occupation) is an important predictor of smoking initiation, cessation and a factor for the increased
smoking prevalence in low-SES populations. Currently in the Netherlands, 10% of people with a
higher education smoke compared to 27% of people with a lower education. Smoking prevalence has
also been shown to vary by income and job type (ref). These disparities in smoking highlight the need
for strategies to reduce smoking-related outcomes by increasing smoking cessation in low-SES
populations.
Why is smoking high in low-SES?
Research suggest that smoking disparities are due a set of factors which are unequally distributed
across the socioeconomic strata. Suggested theories of mechanisms include material and
psychosocial and stress-related factors. Compared to high-SES, low-SES smokers face a number of
factors that may initiate smoking and impede cessations. For example, compared to high-SES, lowSES groups face more stressors in their daily lives, are more financially stressed, have higher nicotine
addition, lack coping mechanisms, lower sense of self-control and self-efficacy, lack social support,
greater exposure to tobacco advertising.
Population-wide strategies, such as cigarette taxation have been effective in reducing smoking
prevalence (ref). However, given that low-SES smokers who already face financial strain, such
strategies may in fact not only impose a greater financial burden but also enhance financial stress and
perceived stress in these groups. As a result, low-SES smokers who continue to smoke are caught in
a vicious cycle: tobacco expenditure damages the financial situation, increases financial stress and
perceived stress, depletes cognitive resources (i.e bandwidth and self-control), impairs decisionmaking, all of which in turn encourages smoking and impedes cessation.
Poorer cessation outcomes have been shown to be associated with financial stress and perceived
stress. Research into the link between stress (i.e financial stress and perceived stress) and cessation
suggests that smoking and stress share a reciprocal relationship: enhanced stress leads to a reduced
probability of cessation and cessation relieves stress levels (Siapush et al, Hajek et al).
Previous interventions
Previous behavioural cessation interventions have been shown to be effective at the general
population-level, however, evidence of their effectiveness in low-SES populations is limited (ref). One
review examining the impact of interventions on an array of health risk behaviours (including smoking)
in low-SES/disadvantaged groups concluded that there was a ‘widespread paucity of evidence about
the effectiveness of changing behaviours in disadvantaged groups’ (Miche et al). Another review
investigating the efficacy of behavior cessation interventions in low-SES/disadvantaged groups
concluded that the methodological quality of prior interventions targeting low-SES groups were of poor
quality (ref). These findings warrant the need for the development of interventions tailored to the
needs of low-SES populations. For example, there have been recent calls exploring the effectiveness
of conducting cessation interventions in settings familiar and trusted to low-SES such as community
centres,
To tackle SES disparities in smoking, the underlying mechanisms linking SES to smoking should not
be viewed in isolation but rather as part of a comprehensive strategy to increase smoking cessation in
low-SES populations. Previous studies suggest that in order to develop effective cessation
interventions targeting low-SES, these interventions should be tailored to the needs of low-SES,
should be delivered in trusted settings such as community centres, should focus on alleviating
stressors, provide social support (in the form of peer or a buddy). In addition,
Therefore, future research should focus on delivering interventions in trusted settings such as
community houses, to focus on alleviating stressors (stress management to manage in a healthy way
with stress), social support in the form of a buddy who can act as buffer and deal with high attrition
rates.
Truly effective prevention and intervention approaches must address relevant psychosocial factors
and future research must consider the multifactorial and interrelated nature of factors that influence
prenatal smoking behavior.
Scarcity in low-SES population
Low-SES face financial scarcity, certainly if they are dealing with debts. Scarcity in the context of
decision-making impairs decision-making. It creates a short-term focused at resolving urgent debt
problems for example. This tunneld vision and trying to deal with urgent matters reduces bandwidth.
This has negative consequences for paying attention, to make rational decisions in the longer term.
Interventions that free up bandwidth create more mental space for other things in life (for example
focusing on quitting smoking). The theory of behaviour shows that interventions in the social
environment influences human behaviour. Interventions based on behaviour theory often have an
unconscious effect and burden
What are the negative effects of long-term poverty on behaviour?
Traditionally, poverty was seen as a result of personal failure. But according to the theory of scarcity,
poverty is seen as a chronic scarcity of financial resources that make it difficult to escape poverty.
People who live in poverty often have to make difficult choices about their scarce money and time, for
example spending time to deal with financial papers. For people who live in poverty, paying bills on
time is not an automatic behaviour. Because of limited resources, conscious decisions will have to be
made. Possible unexpected setbacks might also be perceived harder in low-SES. The realization that
there is no room (e.g. avoiding to receive a fine for a late bill) to make mistakes puts extra pressure on
these groups. In short, dealing with scarcity, puts greater pressure on both the time and cognitive
burden needed for all sorts of daily tasks
Bandwidth and executive functions
Humans have a limited bandwidth to process information. In the context of poverty, when people
experience scarcity, the bandwidth is heavily taxed. This comes because people living in scarcity have
to think extra alongside their daily worries about their financial choices. For the processing of
information, executive functions are also important (collective term for processes that play an
important role in planning, decision processes and behaviour). When bandwidth is taxed, executive
functions function less well. For people in poverty, relatively much of the bandwidth is taken up due to
worries, stress and difficult considerations. This leaves little bandwidth which in turn has an impairs
the functioning of executive functions.
SES differences in nicotine exposure (Chen et al 2019)
SES and # of cigarettes/day (CPD)
CPD is significantly associated with low income (measure of SES)
SES and FTND
Higher nicotine dependence is associated with low income (measure of SES)
SES and topography
What is the problem
Socioeconomic inequalities in health behaviors is a major problem worldwide. Data in Western
countries have consistently shown that compared to high-SES groups, low-SES groups live shorter,
live more years in poor health and have higher mortality rates. SES differences in health are not just
observed between high and low-SES but an almost linear relationship (gradient) between SES and
health is observed. SES inequalities are observed for many different health-related behaviors most
notably for smoking. For example, smoking is more of a problem among those with low education and
income. In the Netherlands, the prevalence of daily smoking ranges from 27% among the lowest
educated to 10% among the highest.
What are the underlying mechanisms (relation to SES=> HRBsHEALTH)
Traditional explanations for SES inequalities in HEALTH
2 potential mechanisms have been mentioned: the materialist/structural and cultural/behavioral
explanations. These explanations are part of the ‘causation mechanism’ which states that SES affects
health. Both explanations identify a set of intermediary factors (mediators) which could possibly
explain the underlying mechanisms between SES and health.
The materialist/structural explanation states that the physical, material conditions of life (e.g.
housing conditions, neighborhood, material deprivation and economic resources) as well as
psychosocial factors (mental strain) are determined by SES and influence health.
The cultural/behavioral explanation states that differences in health-related behaviors (e.g.
smoking, diet, physical inactivity) led to differences in health. Studies have tried to uncover what
intermediary factors contribute to the effect of SES on health. These studies generally examined risk
factors but differentiated between material risk factors, psychosocial risk factors and behavioral risk
factors. The psychosocial risk factors were seen as a separate group of stress-inducing risk factors
(e.g. stressful living, lack of coping strategies, lack of social ties). In the next three decades, several
studies found that a higher exposure to adverse material conditions, psychosocial risk factors and
unhealthy behaviors among low-SES could to a large extent explain the inequalities in health across
SES groups.
The direct and indirect contributions of material, psychosocial and behavioral factors to the explaining
of SES inequalities in health:
The conceptual model suggests three pathways from SES (education, income, occupation) to health:
through 1) material factors (financial strain), 2) psychosocial and stress-related factors and 3)
behavioral factors. Material factors may affect HEALTH directly or indirectly via behavioral or
psychosocial factors. Psychosocial factors may also exert a direct or indirect effect through behavioral
factors. This implies that the different sets of risk factors are possibly interrelated: some risk factors
act upon health through other risk factors such as mentioned previouslyi.
SUMMARY: 4 types of intermediary factors which could explain SES ineq. => Health including
material, psychosocial, cultural and behavioral. Factors exert independently as well as
synergistic effects.
Explanations for SES inequalities in HRBs (e.g. smoking, diet, physical inactivity)
Unhealthy behaviour such as smoking are dynamic and modifiable risk factors that offer possibilities
for interventions and policies to reduce SES inequalities in health. In order to change these behaviors,
relevant determinants (factors that are predictive of health-related behaviors) need to be: 1) identified,
2) understood why they are differentially distributed across SES strata and 3) explain the relationship
between SES and health-related behaviors. Determinants that are predictive of health-related
behaviors (HRB) can be divided into several groups:
Individual: individual (intelligence) psychological (self-efficacy) or biological characteristics
(susceptibility)
Environmental: characteristics of an individual’s environment in which one live (housing,
neighborhood), psychosocial factors (stressors), and social environment (social support)
In order to better contextualize HRBs, studies have adopted the SEM to explain inequalities in HRBs.
SEM encompasses several levels (individual, family, community, etc.) to understand better the SES
gradient in HRB as well as the clustering of unhealthy HRB in low-SES.
Current explanations of SES inequalities in HRBs are:

The economic environment (economic resources to purchase goods) argues that one should
have the economic resources to purchase goods to live healthily. However, empirical research
shows that economic resources only explain a part of the association between SES and
HRBs. Moreover, it also doesn’t explain why expensive behaviors (e.g. smoking) is more
prevalent in low-SES.

The physical environment has been investigated as a potential determinant for SES-HRBs.
However, studies conducted show limited evidence that physical environment contributes to
the SES inequalities in HRBs. Limited evidence of economic and physical environment to SES
inequalities in HRB signifies a need for different explanations.
Other possible explanations offered for the SES inequalities in HRBs are that inequalities in HRB are
not a consequence of ‘social class (difference in economic resources)’ but also of ‘social status
(differences in prestige)’. Bourdieu posited that social inequalities are the result of a differential
distribution of 3 types of capital (institutionalized, objectified and embodied).
SUMMARY: individual, economic and physical environments limited contribution to explaining
SES inequalities in HRBs. Cultural determinant one possible explanation for SES ineq. => HRB.
Why is smoking more prevalent among low-SES groups?
SES inequalities in SMOKING
An inverse association between SES and smoking exists, although the overall mechanisms remain
unclear. Many proposed conceptual models/frameworks attempt to describe potential mediators
(indirect effects) of SES=>SMOKING have been explored.
Suggested mechanisms linking SES->smoking:

Financial strain: proposed theories have hypothesized that chronic stress may account for the
effects between SES=> HRb due to the physiological stress response. Low-SES has been
shown to be associated with distressii,iii.iv

Moolchan et al found proposed a conceptual model for explaining SESSMOKING and found:
differences in smoking initiation, patterns of tobacco use, addiction levels, access to
healthcare, and success in quitting across SES strata

Pampel et al suggested 9 mechanism including stress, cultural capital, knowledge and access
to health risks associated with HRBs, efficacy and agency and social capital (e.g. social
support) v.

Harwood et al posited that psychosocial factors (social tied, perceived control, stress) mediate
the relation between SES and smokingvi.

Buisinelle et al found that neighborhood disadvantage, social support, negative affect/stress
(using PSS Q to assess degree of self-reported stress), and agency were key mediators (in
the causal pathway) of the relation between SES=> smoking cessation across ethnic diverse
populationvii

Martinez et al tested four pathways linking SES to smoking including social cohesion, financial
strain*, sleep disturbance, psychological distress and found that psychological distress had the
largest effect on smoking prevalenceviii.
Mechanisms that reduce smoking cessation rates among low-SESix

Greater exposure to stress

Lack of knowledge (health risks associated with smoking)

Higher nicotine dependence

Reduce social support for quitting

Low motivation

Low self-efficacy

Greater exposure (accessibility and availability of tobacco products in the environment)
Health follows a social gradient. Higher social position (education, income, occupation) is associated
with better health and longevity. Health is to a great extent determined by social, environmental,
economic and cultural factors (social determinants of health). A key way that social determinants
affect health is via psychosocial pathways. Unequal distribution of social determinants of health drives
inequalities in health (physical and mental).
Social stratification results in groups experiencing differential exposures to social determinants
(material, psychosocial, cultural etc.).
Differential exposures arise from the different conditions in which people are born, grown, live and
age. Their effects on health is mediated by psychosocial factors, health-related behaviours and
biological factors.
Material factors: direct and indirect effects on health
Material deprivation (living in poor standards) has a direct effect on health (e.g. poor housing or
dealing with financial strain increases stress which has a negative effect on health). Haushofer and
Fehr et al. identified 25 studies, including RCTs and natural experiments which reported the effects of
increases/decreases in poverty on psychological wellbeing. Overall, increases in poverty are found to
be associated with stress. Also, Haushofer examined whether stress lead to decision-making
behaviours that reinforce poverty. They found that stress lead to risk aversion and time-discounting in
economic decision-making (stress led to a preference for short-term gratification above long-term
gains). Shafir describe evidence for their hypothesis that scarcity (dealing with scarcity of money)
affects mental processes, in term narrowing mental ‘bandwidth’ resulting in people making decisions
that go against their long-term interest. Applying this to poverty, Shafir et al argues that those
experiencing economic adversity are less likely to adopt health-related behaviours, mainly because
their whole attention is focused on coping in the short term rather than planning the future.
Self-control
Low-SES is associated with low perceived control. Low sense of control (locus of control) is
associated with greater levels of stress and lower engagement in health-promoting behaviour.
Self-efficacy and resilience
Self-efficacy (confidence/capability to accomplish a task. Self-efficacy is important to understand how
individuals cope with stressors. Self-efficacy is context-specific (e.g. environment that supports selfefficacy). In the context of psychosocial, reducing stress strengthens self-efficacy.
Social relationships
Humans are social creatures and the quantity and quality of social relationships affect mental health,
health behaviour and health in general. Social relationships can impact health in several ways: social
ties can influence health-related behaviours and social support can buffer stress.
Stress (psychological processes)
Stress is a key concept understanding psychosocial influences on health. Stress is generated by
adverse experiences or situations perceived as adverse and the ability to cope. Stress arises when an
individual appraises a situation being threatening, perceives that it is important to respond and does
not have the appropriate coping response available. Stress is an integral part of the psychosocial
pathway bc stress hormones released in response to stressors have biological effects that leads to ill
health. Stress can activate the HPA axis in the nervous system, which stimulates the release of the
cortisol hormone. Psychosocial factors can create stress through 2 ways: 1) directly via psychological
pathways and 2) indirectly through influences on health behaviour.
Psychological stress can take many different form (difficult relationship, employment conditions, debt,
neighborhood environment, housing conditions). Bodily reactions to repeated or chronic stress
(allostatic load) link the experience of stress with psychological effects associated with adverse health
outcomes.
Good individual coping abilities (resilience, self-efficacy) and social support can buffer the
phycological responses to stressors. However individual coping mechanisms and social support
depends on social, economic and environmental conditions.
Unhealthy behaviours such as smoking has its own complex web of causation, incorporating
individual, community and societal-level factors including psychosocial pathways. Any behaviour can
be thought of as a psychosocial act, in that behaviours respond to the social environment mediated by
individual motivations, capabilities and opportunities. Smoking can create an immediate and shortterm effect on psychological wellbeing (giving pleasure and relieving stress). They extent to which
people control their behavioural control is constrained or enabled by their capabilities, opportunities
and motivation. Psychosocial processes play a role in the decision to start, continue and to quit
smoking. People use smoking as a way of coping with life stressors but the relationship between
stress and smoking is complex. Nicotine is highly addictive, and evidence shows that nicotine
ingested from smoking simulates the production of dopamine which temporarily reduces feelings of
stress but these negative effects rise again once the effect has worn off. As they become addicted
(habituated) to the effects of nicotine, they will smoke more in order to get the same effect (reason for
why low-SES is more addicted to nicotine and have higher nicotine cravings).
The social determinants (education, housing, employment which drive the inequalities in health) of
health approach emphasizes that behaviours cannot be separated from the social, economic and
environmental contexts in which they take place (behaviours are context-specific meaning they are
occur as a result of the individual context)
The mind is a gateway through which conditions of daily life affect health. Social and material
conditions of daily life act through the mind to affect health. Psychosocial pathways are an important
part of the framework of causes that lead to inequalities in health behaviours, yet their influence is
often not recognized in practice and policy.
Prior research (interventions) were focused on changing individual behaviours and did not fully
integrate the effects of living conditions and psychosocial contexts. It has been shown that such
person-based interventions have widened the gap inequalities because of neglecting other contextual
factors (physical environment, the psychosocial context etc.).
Prevention and behavior change services
The complexity of factors affecting health suggests integrated approach (e.g. strategies to change
behaviours e.g. smoking to then reduce illness such as obesity and thereby to reduce health
inequalities.
Summary:
Using an integrated approach to change behaviour:
Locate the behaviour and address wider determinants of health
Use an integrated approach to tackle the problem (in this case ses inequalities in smoking) by
focusing on increasing individual-level coping strategies to reduce stress, having those skills in
pocket, the individual can cope better with different types of stressors  this will leave more cognitive
bandwidth to focus on changing other behaviour (e.g. smoking)
Intervention: use an integrated approach to tackle multiple determinants which lead to ses
inequalities in smoking
1. locate the behaviour and address the wider determinants of health
2. use an integrated approach to tackle the problem (in this case inequalities in smoking)
Low-SES face multiple types of stressors, lack coping strategies, lack social support, have
debts, lack self-control
Intervention using an integrated approach (BeHeathyR):
1. offer stress management program to enhance coping skills
2. buddy support to enhance social support + deal with financial strain
3. having learned the techniques + having more control, social support in the form of buddy
can buffer the effects of stressors faced in daily lives  this will leave more cognitive room to think on
changing smoking behaviour (changing a behaviour requires mind and energy therefore if participants
learn how to enhance their coping skills, how to turn to social support for help, how to deal with their
financial strain problems, they will have less on their mind and therefore have more mind to focus on
changing their smoking behaviour.
Are psychosocial factors mediators of SES and Health?x
Psychosocial factors may serve as pathways connecting SES HEALTH
Low-SES compared to high encounter more negative life events and chronic stressors and interpret
even ambiguous events as more stressful. Exposure to chronic stressors have a direct negative
impact on emotional experiences. Why are low-SES more reactive to stress?
Low-SES maintain a smaller bank of resources (RESERVE CAPACITY)—tangible,
interpersonal and intrapersonal to deal with stressful events.
Reserve capacity to deal with stressful situations is reduced in low-SES b/c:
Low-SES are exposed to more situations requiring them to use their resources
Low-SES environments prevents the development and replenishment of resources to be kept
in reserve
Having fewer stress-dampening resources, which are further reduced by more stress exposures, lowSES are more likely to show greater responsiveness when faced with stress. Elevated negative
emotions and cognitions lead to intermediate physiological pathways and eventually ill health.
Evidence shows that the association between SES and health may in part reflect the psychosocial
pathway of ‘stress’
The context of low-SES is often characterized by frequent exposure to stressors which in turn leads to
ill health.
The behavioural constellation of deprivation: causes and consequencesxi
SES differences in behaviour are well documented but their causes are not well understood. It is by
now understood that a cluster of behaviors is associated with low-SES. This clustering of behaviours
with low-SES is referred to as ‘behavioural constellation of deprivation’. Pepper et al. proposes that
the behavioral constellation of deprivation is a contextually appropriate response to structural and
ecological factors. Haushofer and Fehr et al. argued that poverty may have particular psychological
consequences that can lead to economic behaviours that make it difficult to escape poverty. Previous
literature have shown associations of SES with one specific type of behaviour to explain and not the
associations of SES with a cluster of behaviours (e.g. financial, health and environmental). Pepper et
al. hypothesized that a cluster of behaviours (BCDs) behavioural constellation of deprivation) is
associated with SES.
BCDs have been shown to vary with SES (complex construct, factors which are used to measure SES
include income, education, occupation or wealth). People of lower SES tend to incur in more debt,
save less for the future, invest less in education compared to high-SES. Research has uncovered
SES gradients in a range of health behaviours. Low-SES smoke more, have poorer diet, are less
physically active compared to high SES. Some argue that low-SES exhibit less healthy behaviours b/c
they are unable to ‘purchase’ health. This may true for some behaviours (e.g. buying healthy foods)
but financial constraints cannot explain for why smoking (unhealthy option) which is financially costly
than the healthy one (abstinence) is prevalent among this group. Such clustering of behaviours
contributes substantially to ses inequalities in health and is an enduring conundrum in public health.
which is an expensive behaviour is so prevalent among this group.
Present-future trade offs
BCDs may result from SES differences in trade-offs between present and future. For example, lowSES are more present-biased compared to high-SES. They prefer present rewards above future (e.g.
using money on smoking rather than investing the money for other necessities such as child’s
education). Arguments for such trade-offs between present and future is due attitudes and
perceptions varying across SES groups. Low-SES are more impulsive, less patient, less futureoriented. Other suggestions are stress. Haushoferrxii et al posits that stress causes ‘short-sighted’
decision-making, implying that present-oriented decision making are the result of poor judgment or
impaired cognition. Pepper et al. argues SES differences in being present-biased may represent a
contextually appropriate response related to factors associated with SES.
Biological mechanisms in BCD
There are known SES gradients in mental health, with low-SES suffering from a greater burden of
depression, anxiety. Stress is one major mechanism by which poverty ‘gets under the skin’. Stresses
may become embedded by many routes producing differences in behaviour. Studies have identified
neural mechanisms by which experiences of deprivation might produce behavioural differences. For
example, differences in brain volume has been reported suggesting that factors associated with SES
have effects on brain developments.
Interventions on scarcity and its effect on economic decision-makingxiii
Conventional policy on poverty often targets material scarcity however studies show that despite
efforts in improving the material resources of the poor, poverty still persists.
Recent studies have proposed a novel explanation for the persistence of poverty traps: poverty itself
impairs the quality of decision making by sapping cognitive resources and causing stress and anxiety
(Mani et al 2013, Haushofer and Fehr et al 2014, Carvalho et al 2016, Dean et al 2017). Poverty may
adversely affect decision making and psychological functioning directly. Poverty may also affect
behaviour because the poor spend considerable time and attention simply managing the day-to-day
demands of life under scarcity, and have little mental ‘bandwidth’ remaining to make better decisions
on health, education, investment and employment. Under this view, the risky and impatient decisions
made by the poor may be rooted in scarcity-driven deficits in cognitive and psychological functioning
(Lawrance, 1991). Understanding whether and how scarcity harms psychological functioning is
important for informing interventions designed to alleviate poverty. However, the current evidence is
mixed. While the rural poor in India experience significant impairment to cognitive functioning over the
annual harvest cycle (mani et al 2013), no such effects are found in the urban poor in the US over the
payday cycle. Is the impact of scarcity on functioning generalizable in developed contexts where
material scarcity is less severe? Does material scarcity or bandwidth deficits matter more?
The causal relationship between poverty, psychological function and decision-making (poverty creates
its own mindset, the low-SES focused on what is scarce (money), this depletes the cognitive
resources and as a result affects their economic as well as health behaviours.
Questions:
Why does scarcity produce functional changes in the poor? -->one study studies the extent and
structure of scarcity on decision-making by differentiating between bandwidth taxes and material
scarcity. Previous studies have combined both measures. This study examines each individually
measure to see which has greater effect.
A causal chain between poverty, psychological functioning and economic decision-making?
Previous lab and observational evidence suggest that poverty changes psychological functioning
which in turn alters economic decision making leading to greater risk aversion (risk taking) and
present bias (preferred present rewards above future). There is strong evidence that cognitive
bandwidth taxes are a key mechanism explaining why poverty reduces cognitive functioning,
increases anxiety and ameliorates (enhances) present bias. However changes in material scarcity
have muted effects and poverty-induced
Mechanisms linking poverty to psychological function and decision-making
Material scarcity may directly affect functioning b/c the poor are exposed to more stressors which
directly impairs psychological functioning and decision-making. Material scarcity also imposes
cognitive bandwidth taxes from managing limited income to meet basic consumption needs how?
The poor have limited mental bandwidth to process information and make decisions. They are
vulnerable to demands that requires their attention since they lack access to bandwidth-saving
devices).
Although welfare programs have reduced deprivation, such programs may have ceiling effects and
may have limited reach, if they fail to target and reduce bandwidth taxes by easing the complex
decision constraints faced by the poor.
The search for psychological mechanisms may be challenging as the poor have endured the cognitive
burdens of poverty for years and may have developed strategies for decision-making that rely less on
Howe poverty and cognitive biases can impact behaviour and decision-making
For low-SES, the circumstances and stresses of poverty consume a great deal of their cognitive
abilities, attention and self-control. This decrease in mental bandwidth can contribute to poor
behaviour and decision-making. They may find it difficult to navigate complex processes and struggle
to develop and follow-through on long-term plans and goals because their attention and cognitive
resources are focused on addressing the challenges of poverty such as securing food of supplies for
their families.
Poverty can shape an individual’s cognition, identity and decisions. For example, they have to make
several decisions regarding work/education/financial. Making good decisions for these things costs
time, cognitive energy etc. Conventional economic theory holds that people make rational decisions to
maximize their personal gain. The theory assumes that individual’s self-control, attention and cognitive
resources do not vary under different situations. However, it has been shown that in practice humans
are irrational. They often make decision that are detrimental to their health. Various factors can
influence what choices people make. The context and environment in which people make decisions,
the social groups to which people belong, an individual’s perceptions can also impact choices and
behaviours. The field of behavioural economics has emerged to explain that humans are not rational
decision-makers. Situational and environmental factors such as poverty can affect decisions and
behaviours.
The psychology of scarcity proposes that brainpower (mental bandwidth), including cognition,
attention and self-control are finite resources that can become fatigued. The conditions of scarcity
(financial resources, time etc.) creates unique circumstances that can impact his/her bandwidth, and
as a result, the behavior and decision-making. Mental bandwidth can become taxed under conditions
of economic scarcity when a large amount of mental resources is used. The financial and life worries
associated with poverty and the difficult trade-offs low-SES make on a regular basis reduces their
bandwidth. The cognitive resources we use to learn, remember, make decisions and problem solve
become impaired under poverty. The situational stresses of poverty can be so great that they can
reduce IQ by 13 points. Low-SES facing decisions that require them to analyze complex information
or decide among many choices may find it difficult to do with reduced bandwidth.
The tax exerted on mental bandwidth by poverty inhibits attentions. It drives people to ‘tunnel’ (focus
on solving urgent matters such as putting food on the table). Tunneling keeps the poor busy and
distracts them from other tasks. These distractions can be detrimental in the long run. Tunneling may
also impact the ability to plan long-term. Impaired bandwidth can also negatively impact executive
control which governs planning, willpower and impulse control. Self-control is the ability to control
emotions, desires and behaviours. Controlling behaviours relies on willpower. Limited self-control
leads to humans to sacrifice future rewards for short-term gains. The poor exhibit behaviours that
seem irrational, this as a result of compromised executive control (impaired bandwidth negatively
impacts self-control depleted among low-SES).
Poverty leads to structural changes in the brain. Low-SES often encounter more stressors and if this
stress response is activated too frequently, the parts of the brain responsible for developing executive
function skills such as impulse control, working memory may become impaired.
Compared to high-SES, low-SES don’t have the room to make mistakes especially when money is at
play. In essence, those in poverty lack ‘slack’ (feeling of abundance)
Humans rely on rule of thumbs (heuristics) to guide their decisions and behaviours. Such heuristics
can elicit cognitive biases that can shape our choices and actions in ways that may seem irrational.
Bandwidth consists of cognitive capacity and executive control. Cognitive capacity concerns the
psychological mechanisms that underlie our ability to retain information, engage in logical reasoning
and solve problems. Executive control respectively, underlies the ability to manage cognitive activities,
including planning, controlling impulses, initiating and inhibiting actions. Scarcity 7 reduces both. The
concepts tunnelling and reduced cognitive bandwidth of the scarcity theory have some similarities with
the theory of ego depletion (Baumeister, Bratslavsky, Muraven & Tice, 1998). This theory is about
self-control or willpower which draw upon limited mental resources that can be used. Acts of selfcontrol, responsible decision making, and active choice seem to deplete other vital resources of the
mind such as executive control (Baumeister et al., 1998). When people’s limited capacity for selfcontrol is used up by managing their daily expenses, there is no more ability for selfcontrol left for
decision making about other problems. So, the lack of cognitive resources makes it difficult for people
with lower financial resources to focus on other issues. This is especially true for problems that lay
further in the future (Shah et al., 2012), and could also apply to concerns about health.
Poverty and cognitive load in the form of experiencing stress
Cognitive load refers to the presence of a burden on the cognitive system of an individual. From the
point of poverty research, an increase in cognitive load has been found to be associated with negative
experiences. Haushofer and Fehr found that people living in poverty are more likely to experience
cognitive load in the form of stress due to exposures to adverse economic and social phenomena.
Hence, stress could be bridging factor between poverty and decision-making. From an economic
context, cognitive load can arise from a person living in poverty. People living in poverty may lack
financial and social resources to cope with chronic stressors. Such cognitive load can impede selfcontrol and decision-making. Financial stress can lead to higher exhibited stress levels, cognitive
functions (i.e attention and intelligence) are significantly lower before resolving financial difficulties.
Cognitive load increases selective attention to stressors, amplifies stress levels, and is detrimental to
the ability to diffuse attention to other relevant issues.
Self-control capacity
Self-control is one’s ability to regulate attention, thoughts and behaviours by resisting temptations.
Self-control deteriorates when dealing with poverty. The Resource Model (model of self-control)
describes self-control as an inner capacity-limited resource that can be exhausted when controlling
one’s own behaviour.
Cognitive load can have a negative impact on self-control capacity. As poor groups are constantly
exposed to economic stressors and must make critical decisions, their self-control capacity is
correspondingly decreased. Trying to regulate day-to-day demands can thus lead to reduced selfcontrol. In addition to cognitive load, self-control is driven by attention and working memory.
Baumeister argues that directing attention from oneself to the environment can deplete self-control.
Limited attentional resources cause people to focus on their urgent needs and neglect more distal
stimuli. The depletion of mental resources for self-control can lead to impulsive and intuitive
behaviours that eventually cumulate producing poor economic decisions thus leading to a viscious
cycle of poverty-inducing behaviours.
To summarize, research has shown that poverty impacts executive functions directly, and indirectly
via cognitive load in the form of stress.
Exposure to stress causes one to rely on simpler, more primitive automatic decision-making
preferences. Baumeister (2008) provides evidence that people under stress tend to opt for automatic
instead of controlled processes when making decisions.
people who face scarcity choose unhealthy foods because of the reduced cognitive bandwidth which
causes them to ignore the long-term health benefits of a healthy diet and base their choices on
impulses and on what is convenient, for example.
‘How does scarcity influence the content of cognition?’. The authors reasoned that the content of
thoughts of people who face scarcity must be attuned to the economic dimension of experiences
Health is often the consequence of unhealthy behaviour which occurred a long time before the effect
of the behaviour. For example smoking, which may cause lung cancer after decades of smoking
(Alberg, & Samet, 2003). Maintaining a healthy diet is a long-term goal as well, because eating
unhealthy does not necessarily show much negative effects on the short term. Eventually, it can
contribute to many adverse health outcomes (World Health Organization, 2003). Since cognitive
resources are necessary to think about healthiness of food choice, eating healthy would be more
difficult for those who experience scarcity and can make use of less cognitive capacity as a result.
Previous research showed that eating behaviour is indeed influenced by cognitive load and the
depletion of cognitive resources. People under cognitive load make less healthy food choices,
consume more calories (Zimmerman & Shimoga, 2014) and consume less fruits and vegetables
(ByrdBredbenner, Quick, Koenings, Martin-Biggers, & Kattelmann, 2016). Perhaps, because there is
little cognitive bandwidth left, people make choices about food and eating based on short-term
impulses, on what is convenient and easy to prepare, tasty, and not per se on considerations about
healthiness. Ho
Smoking is a complex behaviour that is affected by several determinants, SES is one of those
determinants. The SES inequalities in smoking has been well documented, yet the underlying
mechanisms that drive the relationship between SES and smoking is not well understood. So far,
several explanatory mechanisms have been proposed including the causation mechanism which
assumes SES has an indirect effect on smoking through an unequal distribution of determinants
across SES strata, with unfavourable determinants being more prevalent among low-SES groups.
Many causal pathways through which SES may influence smoking behaviour have been explored
including 1) material factors, i.e poor housing conditions, lack of economic resources; 2) psychosocial
factors, i.e exposure to stressful situations, adoption of effective coping strategies, ability to control
one’s environment, availability of social ties and social support. These groups of determinants
Other points (Which can be tested in the BehealthyR study)

Test the moderating effect of depression and anxiety between stress and smoking
To further understand the neural mechanisms of the BCD, it would be useful to examine SES
differences in neural responses to decisions involving present-future trade-offs (this could be a
potential lab-experiment)
i
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Baum et al (1999). Socioeconomic status and stress. Does stress account for SES effects on health?
iv
Matthews et al (2010). Are psychosocial factors mediators of SES and health connections?
v
Pampel et al (2010). Socioeconomic disparities in health behaviors
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Harwood et al (2007). Cigarette smoking, SES and psychosocial factors
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Businelle et al (2010). Mechanisms linking SES to smoking cessation
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Martinez et al (2018). A structural equation modelling approach to understanding pathways that connect SES to smoking
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Matthews et al (2010). Are psychosocial factors mediators of SES and health outcomes
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Pepper et al (2017). The behavioural constellation of deprivation. Causes and consequences.
xii
Haushofer et al (2014). On the psychology of poverty
xiii
Ong et al (2017). Reducing debt improves psychological functioning and changes decision-making in the poor.
ii