9.8 Are current strategies to discourage smoking in Australia inequitable?

Last updated: December 2016 

Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.8 Are current strategies to discourage smoking in Australia inequitable? In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-8-are-current-strategies-to-discourage-smoking-i

As described in Section 9.1, smoking rates among those living in the most disadvantaged areas of Australia are double those living in the most advantaged areas. Nonetheless, smoking has declined in all socioeconomic groups over time; the absolute difference in smoking prevalence between the most and least disadvantaged has stayed fairly constant since 2004, and the relative gap has narrowed (see Section 9.2). Victorian research has similarly found that the inequity gap in smoking appears to be narrowing, with the prevalence of regular smoking declining fastest among disadvantaged smokers in recent years.1    

An important consideration in the development of public health policy is whether tobacco control strategies are as effective in reaching low socio-economic groups as they are in reducing smoking among more advantaged people.2-5 The reductions in smoking prevalence have come about from tobacco control policy and subsequent cultural ‘shift’, where the desirability and acceptability of smoking has declined and smoking is increasingly viewed as socially unacceptable. Much of the gain in reducing smoking prevalence is attributable to tobacco control policies, such as public education campaigns and increasingly widespread smokefree regulations. These policies serve to promote public health (for both smokers and for those exposed to secondhand smoke) and change social norms, whereby smoking becomes increasingly less acceptable.6 

There is robust evidence that population-wide strategies such as graphic anti-smoking advertisements and increases in taxes on cigarettes have reduced smoking across all socio-economic groups. Research in Europe concluded that tobacco control policies, both price and non-price related, have helped to reduce the prevalence of smoking in the total population, particularly in lower socioeconomic groups. Such policies may therefore have contributed to a certain degree of narrowing in the gap between advantaged and disadvantaged groups.7  A recent review similarly concluded that increasing the price of tobacco through taxation polices and continuing anti-smoking mass media campaigns are the most effective strategies to reduce inequities in tobacco use.8 Controls on tobacco advertising, promotion, and marketing appear to be equally or more effective among disadvantaged groups.9 Section 9.10 contains further discussion on tobacco-control strategies and their effect on disadvantaged groups.

This section summarises evidence about the relative impact of population-level tobacco control strategies on various socio-economic status (SES) groups and provides links to further discussions on social marketing in Chapter 14 and tax in Chapter 13; both of these are key mechanisms in population-wide tobacco-control strategies.

9.8.1 Impact of mass media

A 2012 review of the impact of mass media campaigns on smoking cessation concluded that higher exposure appears to confer greater benefit on socioeconomically disadvantaged population subgroups, particularly messages that confer the negative health effects of smoking.10 Such campaigns may also be most effective when combined with other tobacco control strategies, such as social support, counselling, pharmacotherapies, and tax increases.11   

A detailed discussion on the impact of mass media can be found in Chapter 14, Section 14.4.

9.8.1.1 Impact of mass media in reducing disparities in smoking-related knowledge

In Australia, television advertising has been extremely effective in raising awareness of the health effects of smoking among blue collar and less educated groups. In the mid-1980s, 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.12, 13  However, studies monitoring the impact of the Quit Campaign introduced in Victoria in 198514 and the National Tobacco Campaign introduced across Australia in 199715-18 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 (see Chapter 14, sections 14.3.1.2  and 14.4.4  for a detailed discussion on the impact of the National Tobacco Campaign in Australia).

Data from wave 5 (2006) of the International Tobacco Control Four Country Survey indicated that over 90% of people reported 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.19

However, disparities are more pronounced in the case of health conditions that have not been the subject of television commercials. Data from wave 5 of the International Tobacco Control Policy Four Country Survey evaluation study indicated, for instance, that Australians with a university education were only 4% more likely than people who had not finished high school to agree with the proposition that smoking causes stroke (a subject of anti-smoking television campaigns in NSW and Victoria in 2007).19 However, they were 15% more likely to agree that smoking causes impotence, a topic which, although covered in newspaper articles, has never been the subject of a television commercial or package health warning in Australia (Figure 9.8.1) 

Figure 9.8.1
Proportion of smokers 18 years and over agreeing that smoking causes stroke (subject of TV advertisement) and impotence (subject of newspaper stories but not TV advertising), Australia, 2006, by educational attainment

Source: Data file provided to Michelle Scollo of the Tobacco Control Unit, Cancer Council Victoria, by Cooper J and Borland R: responses to fifth wave of the International Tobacco Control Four-country Survey, by educational attainment and income adjusted for household size, unpublished data, 2008

Data from Wave 8 (2010–11) of the International Tobacco Control Four-Country Survey provides a comparison to the earlier findings of Wave 5 (2006). Although health knowledge appears to have decreased somewhat— particularly so in relation to respondents agreeing that smoking causes impotence—trends by education have remained relatively consistent between survey waves—see Figure 9.8.2.

 For a timeline of Australian social marketing campaigns see Chapter 14, section 14.3.

Figure 9.8.2
Proportion of smokers 18 years and over agreeing that smoking causes stroke and impotence, Australia, 2010–11, by educational attainment

Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by Partos T, and Borland R. Knowledge Building Team, Cancer Council Victoria. Melbourne. Responses to eighth wave of the International Tobacco Control Four-country Survey, smoking causes stroke and impotence, unpublished data, 2012.

* Note: University education referred to as 'some university' in Wave 8 data.

9.8.1.2 Impact of mass media led campaigns across socio-economic groups in Australia

See Chapter 14, sections 14.3 and 14.4 for a discussion on the impact of mass media led campaigns across socio-economic groups in Australia.

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. Research on the impact of price increases on prevalence has generally found higher responsiveness to price among lower socio-economic groups.920-25  Among people who were still smoking at the end of the first phase of the National Tobacco Campaign in Australia (May 1997 to November 1999), the prevalence of smoking decreased more among blue than white collar groups during the second phase of the campaign (November 1999 to November 2002) when prices of tobacco products increased significantly. Smoking declined by 6.1% in blue collar groups and increased by 0.9% in white collar groups.26 An analysis of smoking prevalence in response to changes in cigarette prices in Australia between 1991 and 2006 similarly found a strong association between price increases on cigarettes and declines in prevalence, which was more pronounced in lower-income groups. One Australian dollar increase in cigarette price was associated with declines of 2.6%, 0.3% and 0.2% in the prevalence of smoking in low, medium, and high-income groups, respectively.27 Recent Victorian research also suggests that an accelerated decrease in the prevalence of regular smoking among low SES people may be attributable to increases to tobacco taxation (as well as increased funding for social marketing campaigns).1

A detailed discussion on the impact of tobacco price increases on low-income groups can be found in Chapter 13, Section 13.11.

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

Socio-economic 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 school children between 1987 and 2005 indicated that smoking prevalence decreased in all SES groups.28 However, the level of tobacco-control activity affected the consistency of change across different SES groups, particularly in teenagers aged 12–15 years, the period of peak smoking uptake. As indicated in Table 9.8.1, in the period of low tobacco-control funding and activity in Australia (1992–1996), smoking prevalence increased among students aged 12–15 years, 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.

Table 9.8.1
Absolute changes in reported smoking prevalence among students aged 12–15 years during high and low periods of tobacco-control activity, Australia, 1987–1990, 1990–1996 and 1996–2005, in schools in various socio-economic status quartiles

Socio-economic status quartiles

Absolute change

1987–90

1990–96 low activity

1996–2005 high activity

Phase 1 (%)

Phase 2 (%)

Phase 3 (%)

Monthly smokers

Lowest

–1

+6

–12

Second

–2

+3

–10

Third

0

+1

–12

Highest

–1

+1

–13

Current smokers (smoked in past week)

Lowest

–1

+5

–11

Second

–2

+2

–9

Third

–1

+1

–10

Highest

+1

–1

–11

Committed smokers (smoked on three days in past week)

Lowest

0

+2

–7

Second

–1

+2

–6

Third

0

0

–7

Highest

–1

0

–7

Source: White, Hayman and Hill 200823

A large study of adolescents across 29 European countries found that tobacco prices were effective in decreasing smoking among boys, regardless of their socioeconomic status.29 Another European study similarly found that stronger tobacco control policies were associated with lower smoking rates, with no significant difference in this association between high- and low-SES adolescents.30

9.8.4 Differential impact of smokefree policies

The initial introduction of smokefree policies generally resulted in greater benefits for higher income and educational groups,24  likely because such policies were adopted earlier in white collar environments. The increasingly widespread introduction of comprehensive smokefree policies covering workplaces and venues such as bars and clubs, as well as cigarette price increases, are just as likely to discourage smoking among low-SES as among high-SES groups31 (see Chapter 15, Section 15.9.5 for further details). A study in Victoria found that significantly more persons in the lower socio-economic group (measured by educational attainment) reported smoking less after the introduction of smokefree hospitality venues compared to those of higher socio-economic status (40% compared with 24%).32   

Research in Luxembourg, which prohibited smoking in public places, on public transportation, and in workplaces in 2006, found that the prevalence of smoking decreased overall by 22.5% between 2005 and 2008, and the reduction was greater among those with a lower socioeconomic status.33 In regards to health effects, Irish researchers concluded that the national smoking ban reduced inequalities in smoking-related mortality.34 Overall, national, comprehensive smokefree policies are more effective at reducing inequities than voluntary, regional, and partial policies.9

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