9.8 Are current strategies to discourage smoking in Australia inequitable?

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. Smoking has declined in all social groups, however the plummeting in smoking prevalence in the highest socio-economic group has not to date been observed in the remaining 80% of the population (refer Section 9.2). 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, they may well have greatly increased.

Whether current tobacco-control strategies are effective in reaching low socio-economic groups has been discussed by several commentators.1-4 Graham comments that the reductions seen in smoking prevalence in developed countries have come about from tobacco-control policy and subsequent cultural 'shift', where the desirability and acceptability of smoking has been eroded and smoking is increasingly viewed as socially unacceptable. Much of the gain in driving declines in smoking prevalence is attributable to tobacco-control policies, through such strategies as population-wide messages that depict the harms of smoking, and environmental regulations that limit smoking in public areas. Graham comments that these policies serve to protect public health (for both smokers and for those unwillingly exposed to smoke) and at the same time generate a shift in social norms, whereby smoking and by extension, the smoker, become increasingly stigmatised. Graham notes that although tobacco-control policy has involved a degree of stigma to effect change, smoking is now disproportionally represented in the most disadvantaged parts of populations, where there are marked inequalities in life expectancy, living standards and health outcomes. Graham recommends that tobacco-control policy and research should be conducted with an appreciation of social class and drivers of social inequality and an understanding of how social class operates to 'produce smoking and smokers as stigmatised'.5

Overseas and local evidence strongly suggest 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 socio-economic groups. International research on the impact of price increases has generally found higher responsiveness to price among lower socio-economic groups6–9 and emerging local evidence echoes these findings.10 Siahpush and colleagues found a strong association between real price increase on cigarettes and declines in smoking prevalence in Australia, particularly so 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.11 Section 9.10 contains further discussion on tobacco-control strategies and the effect on the disadvantaged.

This section examines 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 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.12 In the US, low-education women seem to have been particularly responsive to media-based tobacco-control efforts.9

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 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.13, 14 However, studies monitoring the impact of the Quit Campaign introduced in Victoria in 198515 and the National Tobacco Campaign introduced across Australia in 199716–19 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 more than 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.20

Disparities in knowledge about the health effect of smoking 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 less prominent.21 Disparities are also much 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.20 However, they were 15% more likely to agree that smoking causes impotence, a topic which, while it had been quite frequently reported in newspapers, has never been the subject of a television commercial or package health warning in Australia (Figure 9.8.1).

 

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.

 

Figure 9.8.2

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.

While stroke was a subject of anti-smoking television campaigns in NSW and Victoria in the year 2007, smoking-related impotence has of 2011, not been the subject of a television campaign or featured on cigarette pack warnings. For a timeline of Australian social marketing campaigns see Chapter 14, Section 14.3.

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. Frequent increases in fees and excise and customs duty on tobacco products up until 2001 appear to have had a significant impact on smoking among all socio-economic groups over that time, with a significantly greater effect among those on low incomes. 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.22 Smoking declined by 6.1% in blue collar groups and increased by 0.9% in white collar groups.

A very detailed analysis of changes in monthly smoking prevalence in response to changes in cigarette prices in each Australian state and territory between February 1991 and December 2006 showed that compared with 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.11

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 children in schools located in suburbs with varying degrees of socio-economic disadvantage in all Australian states and territories between 1987 and 2005 indicated that smoking prevalence decreased in all SES groups.23 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

As indicated in the middle columns of Table 9.8.1, 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.

Published research on the effect of cigarette price on young people in Australia is somewhat limited; however a study of Scottish teens and the relationship between smoking and the young people's personal income and parental social class provides further information in this area. West and colleagues' analysis showed the effect of income on smoking was strongest among higher social class youths. Despite the fact that the proportion of weekly income apparently spent on tobacco was greater among lower social class youths, the association of income on smoking was weak or non-existent among lower social class youths.24

9.8.4 Differential impact of smokefree policies

Evidence about the relative impact of smokefree policies on disadvantaged compared with advantaged groups is mixed. Thomas and colleagues reported that such policies generally appeared to result in greater benefits for higher income and educational groups.10 It is likely, however, that this finding reflects the fact that such policies have been adopted earlier in white collar environments. A study by Dinno and Glantz published in 2009 indicated that comprehensive smokefree policies covering workplaces and venues such as bars and clubs, as well as cigarette price increases, are as likely to discourage smoking among low-SES as among high-SES groups25 (see Chapter 15, Section 15.9.5 for further details). Very few studies in Australia have examined the relative impact of restrictions on smoking in workplaces and indoor and outdoor public places. A study in Victoria did find that significantly more persons in the lower socio-economic group (measured by educational attainment) reported smoking less after the introduction of smokefree hospitality venues in Victoria compared with those of higher socio-economic status (40% compared with 24%).26

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