9.10 Further initiatives to reduce tobacco-related disparities in Australia

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In Australia tobacco policy units, health promotion foundations and Quit campaigns are all greatly concerned about socioeconomic disparities in smoking.

Addressing social disadvantage associated with smoking is a key area of the National Tobacco Strategy.8 The Victorian Health Promotion Foundation has established a taskforce to advise on health disparities,12 and addressing tobacco-related disparities is a key component of many public health and tobacco control plans at the state level.309, 310

The National Tobacco Strategy includes four major approaches to reducing tobacco-related disparities:

• maximising use of population-wide strategies that are effective with disadvantaged groups
• tailoring programs and services to ensure access for disadvantaged groups
• addressing social, cultural and economic determinants of smoking and
• incorporating tobacco control into responses to social disadvantage in the welfare sector and in Australia's approach to overseas aid.172

9.10.1 Effectiveness of population strategies with disadvantaged groups

A systematic review of research on the impact of population-wide tobacco control policies published in 2008 found no evidence of a greater impact on higher SES groups for smoking restrictions in schools or workplaces, restrictions on sales to minors, bans of advertising of tobacco products, health warnings or multi-faceted interventions. The review also found significant evidence of greater effectiveness of price increases among those with lower incomes and manual occupations.274

An analysis of nationwide tobacco control strategies in 18 European countries found that countries with the most comprehensive policies had the highest proportion of ex-smokers. National scores on a scale measuring the comprehensiveness of national tobacco control policies were positively associated with quit ratios in all age-sex groups. High and low educated smokers benefited roughly equally from nationwide tobacco control strategies.275

In addition to the two reviews of the effectiveness of population-level tobacco control policies across socioeconomic groups above,274, 275 two further reviews have attempted to specify which strategies are most likely to reduce disparities between advantaged and disadvantaged groups. One of these identified advertising bans, smoking bans in workplaces, removing barriers to smoking cessation therapies, and increasing the cost of cigarettes as having the potential to reduce socioeconomic inequalities in smoking in western European countries.311 The other review concluded that there was good evidence that tobacco taxation, thematically appropriate mass media campaigns and appropriate smoking cessation support services could reduce tobacco-related disparities in New Zealand.312

The potential for further progress with each of these strategies in Australia is discussed below.

9.10.1.1 Taxation to reduce the affordability of tobacco products

Excise and customs duty on tobacco products has not increased in real terms in Australia since November 1999. As outlined in Section 9.8, price affects tobacco use more substantially than any other strategy, particularly among lower socioeconomic groups. Further increasing duties on tobacco products in Australia is therefore likely to be the single-most important thing that could be done to reduce current disparities in tobacco use among adults in Australia.

9.10.1.2 Smokefree policies

Drawing on social diffusion theory, a major US study in 2007 described the obesity epidemic as being spread person to person like a viral infection.313 An analysis by the John F Kennedy School of Government at Harvard University suggests that similar mechanisms could also operate with smoking.314 Policy interventions such as workplace smoking bans affect not only individuals315 but also people in their family and friendship groups. Diffusions theory would predict that the social multiplier effects of smokefree policies will be much greater when they occur in large geographic areas rather than in individual workplaces.316 The recent extension of smokefree policies from offices to blue collar workplaces and from restaurants to pubs—see Chapter 15— could similarly differentially affect cigarette consumption and the acceptability of smoking among blue collar groups. If more blue collar and lower income workers give up smoking in response to the introduction of bans, this should have a multiplier effect among friends and family living in disadvantaged areas.314, 317

9.10.1.3 Pictorial health warnings

Pictorial health warnings introduced in Australia in 2006 may have been more effective in gaining attention among less educated smokers than among smokers with a university education.

Figure 9.29 shows the frequency with which smokers of various levels of educational attainment noticed the pictorial health warnings in the first few months after introduction.

The proportion of smokers who looked at the new warnings often or very often was more than 30% higher among those who had not finished high school than among those smokers with a university education. While low-SES smokers were no more likely than high-SES smokers to report thinking about the harms of smoking as a result of looking at the warnings, they were more likely to report forgoing cigarettes. While generally people with higher levels of education take a more planned approach to quitting, it could be that these graphic warnings are somewhat more effective among lower than higher SES groups in prompting action.

At present, the exact wording of warnings on cigarette packets is mandated in regulations that are reviewed only every few years. And yet new information about the health risks of smoking emerges every couple of days in the medical literature. Cancer councils have called for the introduction of a system that would enable new warnings to be introduced more rapidly in order to include information about new health problems associated with smoking. This could be done not just on the pack itself but also on a website that could be promoted on the packs and at point of sale.320 Such a proposal would be likely to be of greatest benefit to disadvantaged smokers who are less likely to read newspapers. Another suggestion for increasing the effectiveness of warnings with less well-educated groups is to include (in a website listed on the package) not just information in text, but also dramatic video testimonials about the health consequences of smoking.321 As described in Section 9.10.1.5 below, communication theory would suggest that dramatic testimonials are likely to be more effective with disadvantaged smokers.

9.10.1.4 Under-the-counter sales of cigarettes

With a greater density of retail outlets selling tobacco in disadvantaged areas,322 moves to prohibit display of cigarettes in retail areas may well have a greater impact in lower SES children and quitters at risk of relapse.[28]

9.10.1.5 More effective use of mass media

Many commentators have drawn attention to the role of the media in highlighting the risks of very small and very new threats to health at the expense of well-established causes of diseases such as smoking.325 New studies are published every day about the health effects of smoking, however very little of this information reaches the average smoker. Quit Campaigns could put greater effort into encouraging commercial television and radio and tabloid newspapers to report research about the less well-known and newly discovered health effects of smoking. This could be achieved by systematically scanning research reports and producing and distributing media releases on items likely to be of interest to journalists working in these media outlets.326

Researchers and managers working on the development of Quit Campaigns in Australia have gone to considerable lengths to target media placement (both in terms of timing and program and program type) and to pre-test advertisements among low SES groups to ensure that they are attended to by people of lower socioeconomic status.327–332

Increasing interest among researchers about the differential effects of advertising style and content333–335 and the differential effects of mass media advertising among different socioeconomic groups should also provide crucial guidance on advertising content.283, 336 Research in Wisconsin, for instance,337 shows that advertisements promoting the benefits of quitting and the availability of smoking cessation services are more effective in stimulating action in higher SES groups. Promotion of cessation services through television might seem like an attractive idea for increasing use of services by low income groups, but may in fact result in further disparities in smoking as those in more advantaged areas would be more likely to respond.

Investigators believe that emotional narrative communication may be a better method for low SES groups because it does not rely on explicit arguments or information (which require assessment of the merits of the message, and acceptance of the argument/message).338–340 Theorists341 have proposed that narrative messages (messages embedded in the lessons of personal stories) may enhance impact and persuasion through minimising smokers' ability and motivation to counter-argue against a specific argument or message. Emotionally arousing stories are also more likely to be discussed with others,342, 343 and once shared, are more likely to survive and be reproduced.344 Therefore, messages that are personally relevant and emotionally engaging are more likely to increase perceptions of susceptibility to health risks and be passed on to others through interpersonal communication. Narratives are more likely to trigger self-relevant emotional responses, as the viewer is 'transported' or absorbed into the emotional experience of characters with whom they identify.345, 346 The use of stories in public health communication has previously been found to be very effective through education?entertainment347 as well as in anti-smoking advertising.334

9.10.1.6 Harm reduction: a strategy of benefit for disadvantaged groups?

Disadvantaged groups tend to smoke more cigarettes each day and be more dependent on tobacco-delivered nicotine. High rates of mental health problems may also reduce the capacity of many disadvantaged smokers to quit smoking completely. For this reason several commentators have called for consideration of strategies to reduce harm among smokers who are unable to quit and who remain dependent on nicotine. These include encouraging such smokers to switch to Swedish-style oral tobacco (snus) which poses less risk to the individual user and creates none of the problems of second-hand smoke,349 and the introduction of a regulatory framework than helps shift the market away from smoked tobacco towards potentially less harmful products including snus and pharmaceutical-grade nicotine.312, 350–353

9.10.2 Encouraging greater utilisation by disadvantaged groups of cessation treatment and services demonstrated to be effective

Apart from the application of the population-level strategies listed above, encouraging better use of existing services and treatments by low-SES groups also holds promise for reducing inequalities.

Meta-analyses included in US guidelines for clinical practice show that Quitlines can improve a person's odds of quitting by about 60% (increasing abstinence rates from 8.5% to 12.7%). Compared to placebo medication, using nicotine replacement therapy, bupropion or varenicline can almost double a person's chances of success (increasing abstinence rates from roughly 14% to about 25%). If a person both uses medication and gets coaching from the Quitline they increase their odds still further. Adding the Quitline to medication increases the odds of quitting by 30% (increasing abstinence from 23 to 28%). Adding medication to the Quitline increases chances by about 70% (increasing abstinence rates from 14.6% to 22%).354, 355 While many studies of cessation interventions report results stratified by socioeconomic group, unfortunately reviews and meta-analyses of such studies (such as those published as part of the Cochrane Collaboration)394 rarely report on efficacy or effectiveness by socioeconomic status.395

The very high concentration of smokers within particularly disadvantaged neighbourhoods provides the opportunity for highly localised advertising of services and treatments. This could be done for public housing estates and areas serviced by particular shopping centres, rather than merely to postcode or local government areas.

Face-to-face counselling services?

The UK is the only developed country with a national program for the treatment of tobacco dependence, with face-to-face stop-smoking services established first in the most deprived areas of the National Health Service. These are known as Health Action Zones, and have been rolled out to all primary trusts in the country. While services attempt to target disadvantaged groups within each trust by encouraging action by health professionals in more deprived areas, the cost-effectiveness of this labour-intensive approach to smoking cessation is hotly contested.371–375

Supporters of these services point to data that a greater percentage of people from the most compared to the least disadvantaged areas are accessing the services. They argue that although a smaller percentage of people enrolling in clinics in disadvantaged compared to more affluent areas set quit dates, the total percentage of people attempting to quit has been almost five times higher per capita in the most disadvantaged compared to the most affluent areas.376

Critics point out that the percentage of the smokers accessing the service is extremely small. Because the number of smokers in more advantaged areas is smaller and the percentage who succeed in quitting is higher, overall the impact on low-income smokers is probably much more modest in reducing inequalities than might be suggested by the absolute rates of quitting per capita.373 If more high- than low-SES smokers in each area are accessing the services and succeeding in quitting, then these services could even be increasing inequalities.377

Despite a concerted effort for more than 10 years in the UK, the Department of Health states that the overall gap in smoking rates between the most and least advantaged groups is still increasing.378 Nevertheless, the government remains committed to the National Health Service stop-smoking services, and supporters are urging the services to more effectively target the most disadvantaged smokers within and between areas, and to better address higher levels of addiction in lower-SES quitters.374, 375

With much lower density of housing than is common in the UK, face-to-face services are unlikely to be feasible in Australia.

9.10.3 Developing targeted services and approaches for smokers where these are needed

A number of groups in Australia have needs that are unlikely to be adequately met by mainstream initiatives to encourage and support smokers to quit. As indicated in Section 9.6, several major initiatives targeting highly disadvantaged groups are in place in various jurisdictions and sectors in Australia, but these are not uniform across the country. Extending all services nationwide could further assist in the reduction of smoking in among Indigenous people, those who do not speak English, people living with mental illness and people living in institutions.

9.10.4 Promoting educational achievement, mental health and social connectedness

To eliminate SES disparities in tobacco use will require more than increasing quit attempts in disadvantaged groups.

Given the difficulties facing those who have established dependence on tobacco-delivered nicotine, and given that most of the current disparities in tobacco use can be attributed to differential uptake rather than differential rates of cessation, we need to do more to prevent uptake among children, particularly in disadvantaged families.

Price increases and social marketing have considerable impact on children on children from disadvantaged backgrounds. It may also be worth trying to influence disadvantaged children through appeals to their parents, siblings and influential peers.408

Improvements in the social conditions which encourage uptake and continuation of smoking could also reduce uptake of smoking among disadvantaged groups.

While dozens of social problems can be associated with high rates of smoking, it is evident that many of these problems stem from and could be mitigated by the prevention of educational failure in children. Young people who do well at school are more likely to understand information about health risks and are more likely to feel connected to school and to feel hopeful about their future. If they succeed in further education and get a good job, they are much less likely to end up in stressful personal circumstances, or to be part of social groups where lots of people smoke.

As Hilary Graham and her colleagues have demonstrated

educational trajectories (as measured by age of leaving education and educational qualifications) are associated with smoking, with uptake in adolescence as well as current smoking, heavy smoking and quitting in adulthood. Education eliminates the effect of childhood circumstances on these dimensions of smoking status, suggesting that childhood conditions exert their influence through education. Education in turn determines adult socioeconomic position, with poor adult circumstances adding further to the risk of smoking in adulthood and reducing the odds of quitting.189 p ii8

Preventing educational failure is partly about the science of literacy and numeracy, but it's also about helping schools to work more effectively. Readiness for school, children's mental health and connectedness with school and community are also important and could help to prevent development of mental health problems and a range of other social problems, all of which are highly correlated with smoking uptake.409, 410

Findings of American research on the association between social cohesion and lower smoking rates,411 and the relationship between social cohesion and self-reported health status412 suggests that improvements in social capital could also help to reduce smoking uptake. European research suggests that policies to reduce the ugliness and disorder of the most disadvantaged neighbourhoods and provide opportunities for young people to participate in activities that build a sense of community may reduce risk-taking behavior including smoking.413, 414

Given the crucial contribution of smoking to the perpetuation of social disadvantage, investment in measures to accelerate the decline of smoking among the less advantaged sections of the population is a public policy likely to yield substantial social as well as financial returns.