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

Lower socio-economic status (SES) smokers tend to have higher levels of dependency on tobacco-delivered nicotine as measured by time to first cigarette in the morning, and heaviness of smoking.1 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 such treatments and services are affordable, accessible and attractive to disadvantaged smokers.

9.9.1 Quitlines

In the US, a national telephone helpline promoted through television advertising was used more by disadvantaged groups than by other population segments.2, 3 Data on individual-level measures of SES are not collected on callers to the Australian national Quitline, but analysis of caller postcodes provides some indication of trends within different socio-economic 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 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 less affluent suburbs.4 This finding is consistent with the greater health and consumer literacy of people with higher levels of education. Although the rate of calls was significantly higher among people from the most compared with the least affluent suburbs, there was almost no difference in call rates between the middle three socio-economic quintiles.


Figure 9.9.1

Figure 9.9.1
Average number of calls per month to the Quitline per 100 000 smokers, Victoria, Australia, 2001–04, by quintile of disadvantage

Source: Siahpush, Wakefield, Spittal and Durkin 20074

The study by Siahpush and colleagues also showed that increasing the level of TV advertising was at least as effective in prompting additional calls to the Quitline in lower, compared with 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 with periods without any TV advertising.4

Data combined from waves six, seven and eight of the International Tobacco Control (ITC) Four-country Survey (years 2008 to 2010, during which time spending on media campaigns was substantially higher than the previous six years) suggests that among Australians still smoking at the time they were last surveyed, those in the lowest income group were no less likely and may have been slightly more likely than other smokers to have ever called the Quitline (Figure 9.9.2).


Figure 9.9.2

Figure 9.9.2
Proportion of smokers who received advice or material from the Quitline in the past year, Australia, combined waves six, seven, eight from ITC 4-country survey, 2007–10, by annual household income

Source: Data file of responses (combined) to sixth, seventh and 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

9.9.2 Disparities in use of treatments for tobacco dependence Disparities in use of treatments

Evidence from the US suggests there may be socio-economic differences in the products and services used to quit smoking by people of different socio-economic groups, with lower-SES groups less likely to use pharmacotherapies.5 In addition, disparities have been observed among particular groups in receipt of prescriptions for cessation medications, and the likelihood of filling them.6 A study from New Zealand also reported differences in uptake of treatments by ethnicity, with persons of Pacific and Māori origin being less likely to claim nicotine replacement therapy (NRT) than persons of European origin, despite high smoking rates in the former group, and NRT being available at a subsidised rate in New Zealand.7

Australian smokers may in the past also have tended to underrate the potential usefulness of services to support quitting and medicines to treat tobacco dependence and this is particularly true for smokers in low-income groups.8, 9 In a review of experimental and focus group research published in 2002, smokers on low incomes were less likely to report having used NRT, with some evidence that cost is a barrier to use of this treatment.8 A trial intervention conducted in Australia, which offered subsidised NRT in addition to a Quitline service, found that the offer of subsidised NRT recruited double the number of low-income smokers, compared to the offer of the Quitline service alone. Sixty-three per cent of those who called were first time callers to the Quitline. Those recruited to the intervention group (Quitline service plus subsidised NRT) had higher levels of nicotine dependency than the comparison group (Quitline service only). About 73% of smokers in the intervention group attempted to quit, compared with 61% of smokers in the control group. Quitting outcomes at follow-up among the low-income smokers were 'comparable to quitting outcomes in other studies of mainstream smokers'.10

Figure 9.9.3 presents data from wave eight (2010) of the International Tobacco Control Four-country Survey. It shows prescription medication use on the most recent quit attempt among those who made a quit attempt (since last being surveyed).


Figure 9.9.3

Figure 9.9.3
Proportion of Australian smokers using prescription stop-smoking medications on their last quit attempt, among those who made quit attempts, 2010, by annual household income

Source: Data file of responses to 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 data, although a moderate sample size, shows a gradient across household income groups, with those in the lowest income households more likely than households of higher income to report using prescription stop-smoking medication in their last quit attempt. This data provides some promising evidence to suggest that smokers of lower household income in 2010 no were no less likely to use stop smoking medication to aid a quit attempt.

Figure 9.9.4 also presents wave eight data (2010) of the International Tobacco Control Four-country Survey on all smokers, not just those that made a quit attempt since last being surveyed. It shows that low income smokers were no less likely to make a quit attempt than the highest income smokers. Like Figure 9.9.3, smokers in the lower income brackets were actually more likely than those of the highest income bracket to use a prescription stop-smoking medication aid in their most recent attempt. There was quite a difference in particular between the high income groups using a prescription stop-smoking medication in their quit attempt (11.6%), compared with those in the lowest income group (18.4%). It is worth noting that these figures represent use of prescriptions medications only in the last quit attempt–so those who did not answer 'yes' to using a prescription medication in their most recent quit attempt may still have used prescription medication in previous quit attempts during the survey period (July 2010 to December 2010), or the smoker may have been prescribed stop-smoking medication but had not used it, or made a quit attempt. Therefore it is possible these figures may very slightly underestimate prescription medication use.


Figure 9.9.4

Figure 9.9.4
Proportion of Australian smokers using prescription stop-smoking medications on their last quit attempt and smokers who did not make a quit attempt, 2010, by annual household income

Source: Data file of responses to 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

Bupropion (known as 'Zyban') has been listed on Australia's Pharmaceutical Benefits Scheme (PBS) since February 2001 and varenicline (under the trade name 'Champix') since January 2008. Before 2011 in Australia, NRT was not subject to subsidies under the PBS), with the exception of NRT patches, which have been available to Aboriginal peoples and Torres Strait Islanders at a subsidised rate since March 2008. (Patches have also been available to veterans under the Repatriation Benefits Scheme since 1994–see Section 7.16.1.)

However from 1 February 2011, the listing for subsidised NRT patches on Australia's PBS was extended to include all Australians (both general and those eligible for concessions). Figure 9.9.5 shows the substantial increase in uptake of anti-smoking medications among concession patients since the listing of subsidised NRT patches in 2011.


Figure 9.9.5

Figure 9.9.5
Number of prescriptions filled for anti-smoking medications under the Pharmaceutical Benefits Scheme, Australia, January 2008 to December 2011: concession prescriptions versus ordinary prescriptions

Source: Medicare Australia 201111

Note: Includes prescriptions for bupropion (Zyban) and varenicline (Champix) from January 2008 and nicotine replacement therapy from January 2011

The number of prescriptions for anti-smoking medications processed under the Pharmaceutical Benefits Scheme increased from an average of approximately 42 000 prescriptions per month in 2009 and 2010 to more than 54 000 prescriptions per month throughout 2011. The increase in prescriptions was largely among patients eligible for concessions: the average monthly prescriptions for concession patients increased by 65% while the increase among non-concession patients was only 1.2%. While 45% of patients prescribed bupropion and 39% of patients prescribed varenicline in 2011 were healthcare card holders or other concession patients, almost 76% of those prescribed NRT were concession patients. Disparities in compliance with treatment

A study of smokers using NRT in the general US community (i.e. NRT purchased over the counter rather than prescribed by their doctor) 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.12

Similarly a study of smokers using cessation services in the UK (which included group program and one-to-one behavioural support, as well as the offer of pharmacotherapy) reported that at 52-week follow up, 14% of smokers of higher-SES had remained quit, compared with about 5% of smokers in the lowest socio-economic group. The researchers concluded treatment compliance was one of the factors relating to disparity in quitting success.13

9.9.3 Disparities in provision of quit smoking advice and referral by general practitioners

Data from the seventh wave of the International Tobacco Control Four-country Survey (between October 2008 and March 2009) showed that smokers of lower educational attainment were more likely than any other group to report being advised to quit smoking by their doctor. There was a slight increase from 2006 among smokers who had completed schooling, obtained a trade qualification or completed some university reporting being advised to quit (up from 51%, 52% and 48% respectively).

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 general practitioner identification of smokers, advice to quit, and use of NRT and the Quitline by lower-SES smokers.


Figure 9.9.6

Figure 9.9.6
Proportion of smokers who could recall having been advised to quit by their doctor, Australia, 2008–09, by level of educational attainment

Source: Data file of responses to seventh 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

Recent news and research

For recent news items and research on this topic, click here (Last updated October 2016)      


1. Hyland A, Borland R, Li Q, Yong HH, McNeill A, Fong GT, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15 Suppl 3:iii83-94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16754952

2. Sood A, Andoh J, Verhulst SJ, Rajoli N, and Hopkins-Price P. Characteristics of smokers calling a national reactive telephone helpline. American Journal of Health Promotion. 2008;22(13):176–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18251117

3. Andoh J, Verhulst S, Ganesh M, Hopkins-Price P, Edson B, and Sood A. Sex- and race-related differences among smokers using a national helpline are not explained by socioeconomic status. Journal of the National Medical Association. 2008;100(2):200–7. Available from: www.nmanet.org/images/uploads/Journal/OC200.pdf

4. Siahpush M, Wakefield M, Spittal M, and Durkin S. Anti-smoking television advertising and socio-economic variations in calls to Quitline. Journal of Epidemiology and Community Health. 2007;61(4):298–301. Available from: http://jech.bmj.com/cgi/content/full/61/4/298

5. Lillard DR, Plassmann V, Kenkel D, and Mathios A. Who kicks the habit and how they do it: socioeconomic differences across methods of quitting smoking in the USA. Social Science & Medicine 2007;64(12):2504–19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17418470

6. Solberg L, Parker E, Foldes S, and Walker P. Disparities in tobacco cessation medication orders and fills among special populations. Nicotine & Tobacco Research. 2009;12(2):144–51. Available from: http://ntr.oxfordjournals.org/content/12/2/144.long

7. Thornley S, Jackson G, McRobbie H, Sinclair S, and Smith J. Few smokers in South Auckland access subsidised nicotine replacement therapy. The New Zealand Medical Journal. 2010;123(1308):16–27. Available from: http://www.nzma.org.nz/journal/123-1308/3943/

8. Borland R, Pigott R, Rintoul D, Shore S, and Young S. Barriers to access of smoking cessation programs, nicotine replacement therapy and other pharmacotherapies for the general Australian population and at-risk population groups. Final Report to Australian Government Department of Health and Ageing. Literature Review vol 1. Canberra: VicHealth Centre for Tobacco Control, Cancer Council Victoria, 2002.

9. Carter S, Borland R, and Chapman C. Finding the Strength to Kill Your Best Friend - smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf

10. Miller CL, and Sedivy V. Using a quitline plus low-cost nicotine replacement therapy to help disadvantaged smokers to quit. Tobacco Control. 2009;18(2):144-9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/2/144

11. Medicare Australia.Pharmaceutical Benefits Schedule Item Reports [database on the Internet] .Canberra, Australia Australian Government Medicare Australia. 2011 [cited 9 May 2012] . Available from: https://www.medicareaustralia.gov.au/statistics/pbs_item.shtml.

12. Burns E, and Levinson A. Discontinuation of nicotine replacement therapy among smoking-cessation attempters. American Journal of Preventive Medicine. 2008;34(3):212–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18312809

13. Hiscock R, Judge K, and Bauld L. Social inequalities in quitting smoking: what factors mediate the relationship between socioeconomic position and smoking cessation? Journal of Public Health. 2010;33(1):39-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21178184

Recent references

Kennedy, M., M. Genderson, A. Sepulveda, S. Garland, D. Wilson, et al., Increasing tobacco quitline calls from pregnant African american women: the `one tiny reason to quit' social marketing campaign. Journal of Women's Health, 2013. 22(5): p. 432–8. Available from: http://online.liebertpub.com/doi/full/10.1089/jwh.2012.3845

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