9.8 Are current strategies to discourage smoking in Australia inequitable?

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As described in Section 9.1, smoking rates among those living in the most disadvantaged areas of Australia are still more than double those living in the most advantaged areas. Smoking has declined in all social groups. However, the plummeting in smoking prevalence in the highest socioeconomic group has not to date been observed in the remaining 80% of the population—refer Section 9.2. This has led some commentators to conclude that current tobacco control policies are ineffective with low socioeconomic groups.69

It must be remembered that smoking rates have been higher among disadvantaged groups since long before the introduction of tobacco control policies, and that in the absence of tobacco control policies may well have greatly increased.

Both overseas and local evidence strongly suggests that population strategies such as graphic television advertising of the health effects of smoking and increases in taxes on cigarettes in fact have reduced smoking across all socioeconomic groups. International research on the impact of price increases has generally found higher responsiveness to price among lower socioeconomic groups.[27] 48, 270–272 See Section 9.10 for further details.

This section examines evidence about the relative impact of population-level tobacco control strategies on various SES-groups.

9.8.1 Impact of mass media

A meta-analysis of the most rigorous studies since 1980 on the impact of mass media advertising has shown that such campaigns are effective across education levels and different racial groups.273 In the United States, low education women seem to have been particularly responsive to media-based tobacco control efforts.272

9.8.1.1
Impact of mass media reducing knowledge disadvantage of less educated groups in Australia

In Australia, television advertising has been extremely effective in raising awareness of the health effects of smoking among blue collar and less educated groups. Data from the International Tobacco Control Four country survey indicates that over 90% of people report having noticed publicity on television on smoking in the last six months, with no differences in level of awareness between groups with various levels of educational attainment.64

In the mid-1980s in Australia, people with limited formal education and blue collar workers were much more likely than people with post-school qualifications and white collar workers to believe that no illnesses were caused by smoking, and that some illnesses were helped by smoking.276, 277 However, studies monitoring the impact of the Quit Campaign introduced in Victoria in 1985278 and the National Tobacco Campaign introduced across Australia in 1997279, 280 indicate a steady increase in knowledge among people with all levels of education about the health effects of smoking such as emphysema, heart disease, stroke and macular disease which were the subject of television commercials used in the campaigns.

Disparities in knowledge about the contents and health effects still exist, but these are much less pronounced in Australia than they are in the UK where TV advertising on the health risks of smoking has been much less prominent.281 Disparities are also much more pronounced in the case of health conditions that have not been the subject of television commercials. Data from the International Tobacco Control Policy Evaluation study indicate, for instance, that Australians with a university education are only 4% more likely than people who have not finished high school to agree with the proposition that smoking causes stroke.64 However they are 60% more likely to agree that smoking causes impotence, a topic which, while it has been quite frequently reported in newspapers, has never been the subject of a television commercial or package health warning in Australia—see Figure 9.22.

Those who have not finished high school are just as likely as those who have a university qualification to know that 'light' cigarettes are not less harmful than standard cigarettes.64 This issue has been the subject of extensive television advertising by Australia's Competition and Consumer Commission.

9.8.1.2 Impact of mass media led campaigns across socioeconomic groups in Australia

Analysis of smoking prevalence over the period of the National Tobacco Campaign in Australia shows that the effect of the campaign on smoking rates among blue collar groups was of similar magnitude to the effect on white collar groups. Between 1997 and 1999, prevalence fell 3.9 percentage points in blue collar groups, and 3.7 percentage points in white collar groups.282 As indicated in Figure 9.23, prevalence has fallen roughly equally among all occupational groups over the life of the campaign.

This is consistent with results of earlier research which showed no increase in the disparity between smoking rates among groups with different levels of education after the early Quit Campaigns in Sydney and Melbourne.278, 283

9.8.2 Differential impact of price increases on low-income groups in Australia

Cigarettes in Australia are among the most expensive in the world—see Chapter 13. Frequent increases on fees and excise duty on tobacco products up until 2001 appears to have had a significant impact on smoking among all SES groups over that time, with a significantly greater effect among those on low incomes. A very detailed analysis of changes in monthly smoking prevalence in response to changes in cigarette prices in each Australian state between February 1991 and December 2006 showed that, compared to people on moderate and high incomes, a higher percentage of people on low incomes stopped smoking in response to increases in the price of cigarettes.284

Among those people who were still smoking at the end of the first phase of the National Tobacco Campaign in Australia (May 1997 to Nov 1999), the prevalence of smoking decreased more among blue than white collar groups during the second phase of the campaign (Nov 1999 to Nov 2002) when prices of tobacco products increased significantly.285 Smoking declined by 6.1% in blue collar groups and increased by 0.9% in white collar groups.

9.8.3 Differential impact of campaigns and price increases on disadvantaged children in Australia

Socioeconomic trends in smoking prevalence among Australian children also appear to reflect overall levels of tobacco control funding and taxation policy.

A study of smoking among children in schools located in suburbs with varying degrees of socioeconomic disadvantage in all Australian states and territories between 1987 and 2005 indicates that smoking prevalence decreased in all SES groups.39 However, the level of tobacco-control activity affected the consistency of change across different SES groups, particularly in teenagers aged 12 to 15 years, the period of peak smoking uptake. As indicated in Table 9.14, in the period of low tobacco-control funding and activity in Australia (1992–1996), smoking prevalence increased among 12- to 15-year-olds, with the greatest increase among low SES students. In a period of high tobacco-control activity (1997–2005), by contrast, smoking decreased quite sharply and reductions were consistent across SES groups.

As indicated in the middle columns of Table 9.14, the prevalence of smoking increased very sharply in low SES teenagers during the period of low tobacco control activity, whereas there was little change among the higher SES teenagers.