9.9 Are there inequalities in access to and usage of treatment for dependence on tobacco-delivered nicotine?

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Lower SES smokers tend to have higher levels of dependency on tobacco-delivered nicotine, and for this reason they may be more likely to benefit from services and treatment that support people to overcome cravings and to deal with slip-ups. This and their lower incomes place a special responsibility on government to ensure that treatments and services are affordable, accessible and attractive to disadvantaged smokers.

9.9.1 Quitlines

In the United States, a national telephone helpline promoted through television advertising was used more by disadvantaged groups than by other population segments.301, 302 Data on individual-level measures of socioeconomic status are not collected on callers to the Australian national Quitline, but analysis of caller postcodes provides some indication of trends within different socioeconomic groups, as do population surveys that ask smokers about their use of services.

A study of calls to the Quitline in Victoria over the period between January 2001 and March 2004 showed that in periods without television advertising, people living in the most affluent suburbs were 60% more likely to call the Quitline than people in the least affluent suburbs.303 This finding is consistent with the greater health and consumer literacy of people with higher levels of education.

But note that, although the rate of calls was significantly higher among people from the most compared to the least affluent suburbs, there was almost no difference in call rates between the middle three socioeconomic quintiles.

Increasing the level of TV advertising was at least as effective in prompting additional calls to the line in lower compared to higher SES groups. A high level of target audience rating points (TARPs) resulted in a 273% increase in calls in the lowest quintile and a 250% increase in the highest SES quintile when compared to periods without any TV advertising.

Surveys of current smokers which did collect information about individual income and education show a slightly different picture. Among people still smoking or only recently quit smoking in 2006, those in the lowest income groups were no less likely and may have been slightly more likely than other smokers to have ever called the Quitline—see Figure 9.25.

Regardless of which is the more accurate assessment of the relative use of the Quitline by SES, it would be beneficial to greatly increase usage among the most disadvantaged groups.

9.9.2 Disparities in use of treatments for tobacco dependence

9.9.2.1 Disparities in use of treatments

Evidence from the US suggests there may be socioeconomic differences in the products and services used to quit smoking by people of different socioeconomic groups, with lower SES groups less likely to use pharmacotherapies.304 Australian smokers also tend to underrate the potential usefulness of services to support quitting and medicines to treat tobacco dependence and this is true for smokers in low income groups.305, 306

Smokers on low incomes are less likely to report having used nicotine replacement therapies, with some evidence that cost is a barrier to use of this treatment.305

Data from the International Tobacco Control Policy Evaluation Study indicate that the least well-educated and lowest-income smokers may have been slightly less likely to notice advertising for stop-smoking medicines.

In contrast to nicotine replacement therapies on which no subsidies are available for sale, bupropion has been listed on Australia's Pharmaceutical Benefits Advisory Scheme since February 2001, so that it seems unlikely that cost would be a barrier to its use.

Data from the International Tobacco Control Policy Evaluation Study indicate that, of people still smoking or only recently quit smoking in 2006, those in the lowest income quintile may have been slightly more likely than smokers in other income groups to have been prescribed Zyban by their GP.

Data from Medicare Australia indicate that of the 750,000 prescriptions issued for bupropion in Australia between February 2001 (when it was first listed on the Pharmaceutical Benefits Scheme) and June 2007, almost half were provided to people who were eligible for pensions, benefits or the government health care card..307

9.9.2.2 Disparities in compliance with treatment

A study of smokers using nicotine replacement therapies (NRT) in the general community has indicated that those with very low incomes and those of minority status were much more likely to discontinue NRT use if they had slipped up, if they suffered side effects, or if they felt that it wasn't helping with quitting.308

There may well be scope for improving the quality of use of medicines to treat tobacco dependence among disadvantaged smokers in Australia.

9.9.3 Disparities in provision of quit smoking advice and referral by GPs

Data from the International Tobacco Control Policy Evaluation Study indicate that smokers on low incomes were no less likely to visit their general medical practitioners in the previous year than smokers on high incomes.

Smokers on low incomes and with more limited education were no less likely to have been referred to the Quitline, and they were actually more likely to report having been advised to quit by their general practitioner.

There is little evidence of inequities in access to pharmacotherapies and services for treatment of tobacco dependence in Australia. However given the higher level of dependency and less than optimal use of available services and treatments, there is still scope for improving GP identification of smokers, advice to quit, and usage of NRT and the Quitline by lower-SES smokers.