In Australia, tobacco control policy units, health promotion foundations and Quit campaigns are all greatly concerned about socio-economic disparities in smoking.
Addressing social disadvantage associated with smoking is an objective of Australia's National Tobacco Campaign that operates under the auspices of the Australian National Preventive Health Agency (ANPHA). The National Tobacco Campaign aims to reach high-need and highly-disadvantaged groups through a multi-tiered targeted social marketing campaign.1 Reducing disparities and disadvantage is also subject of state-based tobacco control initiatives, including the Tackling Tobacco Program operating in NSW2 and the Tobacco and Mental Health project in South Australia. 3 The Victorian Health Promotion Foundation (VicHealth) has established a program to reduce health inequalities among Victorians though a focus within its program areas on determinants such as social connection or race-based discrimination, or risk factors including smoking and alcohol consumption.4 Reducing smoking among disadvantaged groups is also a key priority for Quit Victoria.5
The following presents what is known about the effects of population-wide strategies and targeted interventions on disadvantaged groups and on tobacco-related disparities.
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 socio-economic groups for smoking restrictions in schools or workplaces, restrictions on sales to minors, bans of advertising of tobacco products, health warnings or multi-faced interventions. The review also found significant evidence of greater effectiveness of price increases among those with lower incomes and manual occupations.6 Main and colleagues' review of 19 systematic reviews of population-level tobacco control interventions that reported on at least one socio-demographic characteristic found that few studies attempted to analyse effects by SES–something which they felt should be explicitly addressed in future reviews and in research of intervention efficacy. Overall there was little to suggest lower levels of effectiveness among disadvantaged groups. They concluded that there was preliminary evidence to suggest that increasing the unit price of tobacco may reduce smoking related health inequalities.7
An analysis of nation-wide 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 nation-wide tobacco control strategies.8
In addition to these three systematic reviews of the effectiveness of population-level tobacco control policies across socio-economic groups above,6, 8 two papers have assessed available research and specified 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 socio-economic inequalities in smoking in western European countries.9 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.10
The potential for further progress with each of these strategies in Australia is discussed below.
Before April 2010, excise and customs duty on tobacco products had not increased in real terms in Australia since November 1999. On 30 April 2010, the Australian Government raised the excise on tobacco products by 25%, making Australian cigarettes among the least affordable in the world. Smoking prevalence in the least advantaged households declined significantly in Australia between 2007 and 2010, as reported in the National Drug Strategy Household Surveys11, 12 after several periods of little change in this part of the population.11, 13 The most commonly reported reasons for changes in smoking behaviour among smokers in 2010 were because smoking was affecting their health, and because it was costing too much. 12
Price affects tobacco use more substantially than any other strategy, and it seems that this is particularly so among lower socio-economic groups. Australian research reports that tax increases in the past have had a substantial impact on smoking in low socio-economic groups.14-16 Several substantial reviews have examined studies assessing the effect of price increases on smoking and tobacco consumption among disadvantaged groups.6, 17-19
Analysis of data from the International Tobacco Control Policy Evaluation (ITC) Four-country survey suggests that while behaviours to avoid high prices and tax on tobacco products are common across all socio-economic groups, low-SES smokers in the UK, Canada, Australia and the US are on average 25% more likely to engage in one or more behaviours to avoid or minimise paying tax on tobacco products compared with those of higher socio-economic status. For example, those in the low-SES group were 85% more likely than high-SES respondents to use discount brands or roll-your-own (RYO) cigarettes. Higher socio-economic groups in comparison were more likely to report traveling to an area of low-tax, purchasing tobacco duty-free or purchasing in cartons rather than individual packs. Given the findings of the analysis, the researchers concluded that reducing price differentials between discount and premium brands may have a greater impact on low-SES smokers.20
For a further detailed discussion on tobacco price and impacts on low socio-economic groups, see Chapter 13, Section 13.11.
Policy interventions such as workplace smoking bans affect not only individuals21 but also people in the family and friendship groups of those affected.
Smokefree workplace policies reduce the amount of tobacco smoked, reduce exposure to secondhand smoke and reduce the chances of a quitter relapsing. There is also evidence that they increase quitting.19
Drawing on social diffusion theory and a wealth of data collected since 1970 from the landmark Framingham study, a major US paper published in the New England Journal of Medicine in 2007 described how social behaviours such as weight loss and quitting can be spread person to person like a viral infection.22 A further study published in 2008 showed that ever smokers were about 70% more likely to have quit over the previous 30 years if their spouse had quit, about 25% more likely if a sibling had quit, 36% more likely if a friend had quit and 34% more likely if a co-worker had quit.23 A study by the John F Kennedy School of Government at Harvard University went on to use network analysis to demonstrate how workplace smoking bans could contribute to declining prevalence of smoking.24
All Australian states and territories have now implemented bans on smoking in enclosed workplaces, including in hospitality venues–see Chapter 15 for further detail on smokefree policies in Australia. The extension of smokefree policies from restaurants to pubs in Victoria was reported to have a more profound impact on Victorian smokers in the lower socio-economic group (measured by educational attainment), with 40% reporting smoking less after the introduction of the ban, compared with 24% in the higher socio-economic group.25
Many Australian states and territories have in more recent times, extended smokefree policies to cars carrying children, and to outdoor areas, such as playgrounds and outdoor dining areas. The implementation of smokefree cars carrying children has the potential to reduce disparities in health outcomes, by reducing secondhand smoke exposure in children of parents that smoke.
Diffusion theory would predict that the social multiplier effects of smokefree policies will be much greater when they apply to large geographic areas and to many different sorts of venues. The effects of such policies on people in disadvantaged groups should be greater where such policies extend to more blue collar work environments and to a greater range of sporting, hospitality and retail venues.26
Extending smokefree policies to private residences has been generally thought to be beyond the bounds of regulation. Winickoff examines this notion, and points to the potential of smoking bans in high density public housing to reduce secondhand smoke exposure among the disadvantaged.27
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 9.10.1 shows the frequency with which smokers of various levels of educational attainment noticed the pictorial health warnings in the first few months after introduction of the warnings in 2006.
Percentage of smokers rarely and frequently reading new pictorial health warnings on cigarette packets, smokers 18 years and over, Australia 2006, by level of educational attainment
Source: Data file of responses to the fifth wave of the International Tobacco Control Four-country Survey, by educational attainment and income adjusted for household size, provided to Michelle Scollo of the Tobacco Control Unit, Cancer Council Victoria, by J Cooper and R Borland Cancer Council Victoria, 2008.
The proportion of smokers who looked at the new warnings often or very often was 10% 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.
Data from Wave 8 (July 2010–May 2011) of the International Tobacco Control (ITC) Four-country Survey allows comparison with ITC data from 2006–see Figure 9.10.2
Percentage of smokers reporting reading or looking closely at the health warnings on cigarette packets in the past month, smokers 18 years and over, Australia, July 2010–May 2011, by educational attainment
Source: Data file of responses eighth wave of the International Tobacco Control Four-country Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, Cancer Council Victoria, 2012.
The 2010 data shows moderate differences between education attainment level and reading or looking at warning labels on cigarette packets. Those who had some university education were still slightly less likely than those of lower educational attainment or qualification to report reading or looking at warning labels often or very often.
Research conducted in the United States reports a particular impact of pictorial health warnings among smokers of lower socio-economic status. The research found that when comparing text-only warnings with pictorial warnings, participants rated pictorial warnings as more 'personally relevant' and 'effective'. Smokers of low health literacy more notably rated pictorial health warnings as 'credible' compared to text based warnings, yet there was no difference between ratings of credibility of pictorial and text health warnings among smokers of high health literacy.
In addition, graphic pictorial health warnings (e.g. image of fatal lung disease) were rated significantly more 'credible', 'effective' and 'personally relevant' among participants compared with pictorial warnings displaying symbolic imagery (e.g. tombstones representing death) and human suffering (e.g. image of adult female crying). Interactions between the type of pictorial warning and both race and health literacy were also significant, in that, pictorial warning labels with graphic images produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery (i.e. symbolic imagery) produced greater differences. This suggests that graphic pictorial warning labels are most likely to have the broadest effect; eliciting the greatest and most consistent impact across all sub-populations of smokers regardless of race, or level of health literacy.28
A new Standard consisting of two sets of seven pictorial health warnings apiece will commence rotation on tobacco products in Australia leading up to 1 December 2012i, to correspond with the introduction of plain packaging. The new Standard for pictorial health warnings features some new, as well as existing images.29
The size of the pictorial warning has also been increased to cover at least 75%of the front surface of most tobacco product packaging. The Standard maintains the size of 90% of the back surface for cigarette packaging, but requires an increase to 75% of the back surface of most other tobacco products–see Chapter 12, Attachment 1, Section A1.1 for further details.
The data presented above suggest that new warnings required under the 2011 Standard are likely to be at least as effective with low as with high-SES groups.
With a greater density of retail outlets selling tobacco in disadvantaged areas,30, 31 moves to limit the number tobacco retailers in disadvantaged neighbourhoods and/or prohibit display of cigarettes in retail areas may well have a greater impact in lower SES children and quitters at risk of relapse.ii All Australian states and territories have now banned displays at point-of-sale, Chapter 15 provides more detail on point-of-sale display bans.
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 socio-economic status.33-38
Increasing interest among researchers about the differential effects of advertising style and content39-41 and the differential effects of mass media advertising among different socio-economic groups can also provide crucial guidance on advertising content.40, 42 Research in Wisconsin, for instance,43 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).44-46 Durkin and colleagues reported that greater exposure to advertisements containing highly emotional elements or personal stories hold promise for quitting activity in low and mid socio-economic groups.47
Theorists48 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,49, 50 and once shared, are more likely to survive and be reproduced.51 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, because the viewer is 'transported' or absorbed into the emotional experience of characters with whom they identify.52, 53 The use of stories in public health communication has previously been found to be very effective through education–entertainment54 as well as in anti-smoking advertising.40 Victorian research has shown greater increases in calls to the Quitline from low-SES groups were associated with higher emotion narrative advertisements on air compared with other types of anti-smoking advertisements on air.55
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. This might include encouraging individual smokers who have repeatedly failed to quit to switch to Swedish-style oral tobacco (snus) which poses less risk to the individual user and creates none of the problems of secondhand smoke–see Chapter 12, Attachment 3.56 More controversially, other commentators have called for the introduction of a regulatory framework that could helps shift the market away from smoked tobacco towards potentially less harmful products including snus and pharmaceutical-grade nicotine.10, 57-60
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 with placebo medication, using nicotine replacement therapy, bupropion or varenicline can almost double a person's chances of success (increasing abstinence rates from about 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%).61, 62 While many studies of cessation interventions report results stratified by socio-economic group, unfortunately reviews and meta-analyses of such studies (such as those published as part of the Cochrane Collaboration)63 rarely report on efficacy or effectiveness by socio-economic status.64 A systematic review of studies that addressed smoking cessation and improving access to smoking cessation services among disadvantaged groups reported that although many studies collected socio-economic information, only few analysed its association with the results. However, the review did find some evidence from the studies of effectiveness of particular interventions in increasing quitting behaviour in disadvantaged groups. This is discussed further in the next section 22.214.171.124 (refer Murray and colleagues)65
For a discussion on financial incentives and cessation, see Chapter 7, Section 7.17
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 has been hotly contested.66-70
Supporters of these services point to data that a greater percentage of people from the most, compared with the least disadvantaged areas, are accessing the services. They argue that although a smaller percentage of people enrolling in clinics in disadvantage areas compared with 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 with the most affluent areas.71
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.68 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.72
In 2010 the UK Government outlined improvements for the NHS services.73 A systematic review conducted to examine the effectiveness NHS stop-smoking services found some preliminary evidence that NHS services were making a modest contribution to reducing inequalities in health through their support of larger proportions of disadvantaged smokers compared with their more advantaged counterparts. The authors noted, however, that additional research was needed to determine the most effective model of treatment, given that the review suggested group treatment may be more effective than one-on-one treatment. They also recommend further specific analysis of demographic characteristics and the differential impacts/efficacy of interventions among sub-groups, to provide a better picture of the most effective treatment model.74
Murray and colleagues echoed the findings of the research above by Bauld and colleagues pointing to evidence that NHS stop-smoking services are making gains in reaching smokers living in deprived neighbourhoods. Primary care does provide the opportunity to target smokers for cessation interventions, but further research is needed to determine efficacy of this approach among disadvantaged smokers and for quit rates overall.65 Bauld et al note that although support provided by community contacts such as pharmacists may not be as effective as intensive interventions in primary settings, these community-based providers may be in a better position to reach disadvantaged smokers not interested in attending group intervention sessions.74
With much lower density of housing than is common in the UK, face-to-face services are unlikely to be feasible in Australia.
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 through this chapter, 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 nation-wide could further assist in the reduction of smoking in highly disadvantaged groups.
The 'Tackling Tobacco'iii initiative undertaken by the Cancer Council NSW aims to encourage and support non-government social and community services to address smoking among their clients. An evaluation of program results 'challenged assumptions and attitudes that disadvantaged people are uninterested or unable to quit'. It reported clients of these non-government social and community organisations were receptive to receiving quitting support from the trained staff in these services, and the staff providing this care report knowledge and confidence in addressing tobacco among their clients. The program results also indicate improvement in quality of life among clients who do quit smoking.75
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 from disadvantaged backgrounds. Youth and young adults are also sensitive to price increases in tobacco. 17 It may also be worth trying to influence disadvantaged children through appeals to their parents, siblings and influential peers.76
Appreciation of population social conditions when developing health policy 77,78 and improvements in the social conditions which encourage uptake and continuation of smoking can help advance reductions in 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.79pii8
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.80, 81
Findings of American research on the association between social cohesion and lower smoking rates,82 and the relationship between social cohesion and self-reported health status83, 84 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.85, 86.
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.
Thank you to Dr Ron Borland and his colleagues Jae Cooper and Timea Partos for provision of extensive data from the International Tobacco Control Policy Evaluation study, and for many discussions over the years about this topic the authors.
Thank you also to Dr Borland and to the following people for helpful comments on an earlier draft of this chapter: Kylie Lindorff, Dr Sarah Durkin, Dr Vicki White and Dr Melanie Wakefield from Cancer Council Victoria, and to Professor Simon Chapman, University of Sydney.
Thank you to Professor Wayne Hall and Dr Coral Gartner from the University of Queensland for their extremely helpful advice and encouragement, and for provision of unpublished analyses from the National Drug Strategy Household Survey.
Interventions that could balance the factors promoting SES differentials in tobacco use
i Either pictorial health warnings from Australia's old standard (Trade Practices (Consumer Product Information Standards) (Tobacco) Regulations 2004) or the new pictorial warnings from the latest Standard (Competition and Consumer (Tobacco) Information Standard, 2011) are permitted to appear on tobacco product packaging up until 30 November 2012. From 1 December 2012, only the pictorial health warnings from the new standard are permitted to be displayed on tobacco product packaging. See: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/tobacco-label-images
ii While numbers were not large enough to readily detect differences, an Australian study examining impulse purchases following exposure to point-of-sale displays found that smokers in the most disadvantage SES group may have been the most vulnerable.33
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