9.0 Introduction

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Smoking is undoubtedly one of the major markers of and contributors to social disadvantage in Australia.

As with most other high-risk behaviours, the prevalence of smoking is significantly higher among lower socio-economic groups, particularly so in groups facing multiple personal and social difficulties and challenges. Higher rates of smoking are one of the major factors driving poorer health status in economically disadvantaged areas and groups. Spending on tobacco products and ill-health contribute significantly to financial stress. Over long periods, spending on tobacco works against the accumulation of household savings and assets, and perpetuates intergenerational poverty. Financial stress and poverty create social conditions that may make it more difficult to successfully quit smoking. Smoking by pregnant women has far-reaching effects on the health of offspring, both as infants and much later in life. Continued high levels of tobacco use by parents and peers powerfully models smoking, thus perpetuating continuing high levels within neighbourhoods and across generations.

This chapter provides data to illustrate these trends; it analyses some of the factors that may explain the greater likelihood of smoking among disadvantaged groups; finally it draws out policy implications for addressing disparities and reducing social disadvantage associated with tobacco smoking.

9.0.1 What is social disadvantage?

Social disadvantage can be understood, defined and measured in a variety of ways.¹

Social disadvantage is often described in terms of lower socio-economic status as measured by levels of educational attainment, unemployment, being in jobs involving low-skilled manual labour, or earning relatively low levels of income. In Australia, living in a remote as opposed to a rural or an urban area is also often regarded as a form of social disadvantage.

Socio-economic status can be determined at an individual level–based, for instance, on educational attainment, employment status or job type. Alternatively it can be determined at a household level, based on either the income or jobs status of the main income earner, or the combined household income. Or it can be defined at an area level–based on the overall percentages of individuals classified as disadvantaged within particular geographical boundaries.

Socio-economic status can also be quantified in many different ways. People may be categorised into one of two, three, four, five or an even greater number of groups:

• high, medium and low levels of income or earning an income that puts them in one of three tertiles, four quartiles, five quintiles or 10 deciles
• employed, unemployed or not in the workforce
• employed in upper white, lower white, upper blue or lower blue collar jobs or, simply white collar or blue collar
• living in an area with an index of disadvantage in one of four quartiles, five quintiles or 10 deciles.

After each five-yearly census of population and housing, the Australian Bureau of Statistics produces several socio-economic indexes for areas (SEIFA), which take into account relative levels of educational attainment, employment status and income levels of people living in each census area.²

The Index of Relative Socio-Economic Disadvantage is one of four such indexes currently used. This index of disadvantage summarises attributes such as low income, low educational attainment, high unemployment and jobs in relatively unskilled occupations.ⁱ

Other area-based indexes developed by the Australian Bureau of Statistics include:

• the Index of Advantage/Disadvantage, a more recently developed index which is a continuum of advantage to disadvantage
• an Index of Economic Resources which includes variables that are associated with economic resources including rent paid, income by family type, mortgage payments, and rental properties and
• an Index of Education and Occupation, which includes only education and occupation variables.^{2, 3}

None of the indicators described above is entirely satisfactory as a measure of disadvantage. People responding to surveys are often reluctant or unable to describe their current levels of income. Highly skilled tradespeople, while traditionally thought of as 'blue collar' in Australia, may in recent times be earning high incomes due to skill shortages in particular sectors of the economy. Young people competing for jobs in the current decade are much more likely to be economically disadvantaged by lower levels of educational attainment than their grandparents were. Area-level indexes may not work very well in the inner suburbs of the big capital cities, where very wealthy people may live in privately owned dwellings very close to people in subsidised rental dwellings in high-density public housing estates.

Closely related to the concept of socio-economic status are concepts of social differences, social exclusion and social position, which stress people's situation in society relative to other people, and the concept of poverty, usually defined as a measure of family income below a particular level or criteria that has been associated with material deprivation.

In contrast to the highly ordered, categorical variables described above, social disadvantage can also be thought of in terms of more meaningful but less easily quantified indicators of social deprivation, such as: not having good personal relationships and social support^{ii 5} not having adequate, secure and affordable housing; being subject to discrimination or racism; being in poor health; not having private health insurance or access to timely care in the public health system; not having access to good quality childcare or school education; not having work (paid or unpaid) that is fulfilling; and not having income sufficient to always be able to buy essential items and pay bills.

9.0.2 What is health inequality?

Inequality or disparity refers to a state of being uneven.

Socio-economic inequalities are evident for a wide range of high-risk behaviours and social problems, and much is written about the associated and consequent health disadvantage, health gaps and health gradients.

As part of an era of reforms for the National Health Service in Britain, 'health equality' has been given equal billing with 'health gain' in public health policy, and reducing differences in risk factors such as smoking between groups occupying unequal positions in society is a key strategy for achieving that equity. The government papers Healthy Lives, Healthy People and Equity and Excellence: Liberating the NHS have provided a foundation for the Health and Social Care Act 2012. This Act, and related changes under the National Health Service Act 2006, underpin public health reforms in Britain.^6-9

In the US, the Office of Smoking and Health within the government Centers for Disease Control and Prevention has included 'identify and eliminate disparities among population groups'ⁱⁱⁱ as one of its four program goals.^{10, 11} Governments in Australia are also increasingly emphasising health equality.^{9, 12–17}

The concept of inequality–a state of uneven or unequal enjoyment of goods that society values–can be distinguished from that of inequity, which refers to a lack of fairness in the provision of resources, particularly those resources over which governments and publicly funded agencies have control. Inequity occurs if people are discriminated against or if they are denied access to information or services because of failure of service providers to take into account factors such as limited literacy in English, less fluency in speaking English, or living in a remote area and not having a telephone, mobile coverage or internet access.^{18, 19} The issue of inequity is discussed in Section 9.8.

9.0.2.1 Tobacco-related disparities

Tobacco-related disparities are not just a matter of varying smoking prevalence, but can be seen in the inequality between social groups in:

• all forms of exposure to tobacco
  • foetal exposure to tobacco smoke
  • exposure to secondhand smoke in childhood and throughout life
  • exposure through own smoking
• at all points in the continuum of tobacco use¹⁸
  • experimentation
  • reported numbers of cigarettes smoked and patterns of smoking established
  • intention to quit
  • attempts to quit
  • relapse or sustained abstinence or reduction in smoking
• in the relative harmfulness of the type of tobacco used
• in the intensity and duration of smoking
• in the harm that results from use of tobacco
  • financial stress, financial security and accumulation of wealth
  • diseases caused or worsened by smoking
  • deaths and reduced life expectancy.

9.0.2.2 Inequality as deficit, gap or gradient

Tobacco-related inequality can be demonstrated in a variety of ways, most simply by comparing rates of use of and exposure to tobacco in the lowest and highest socio-economic groups. Another test of inequality is the presence of a clear social gradient–for instance where the smoking rate is lower in the most advantaged quartile than in the second quartile, and lower in the second quartile than in the third, and lower in the third quartile than in the fourth (or least advantaged).

Differing understandings of disadvantage give rise to different policy goals in relation to reducing inequalities, each arising from a different set of ethical arguments and each requiring slightly different strategies and approaches.^{20, 21}

If the policy goal is to reduce the extent of the problem of very high levels of high-risk behaviour in the lowest socio-economic group, then the strategy will be to maximise improvement in the most disadvantaged group, regardless of what happens in the more advantaged groups. In this case, the policy goal–of reducing the deficit among the disadvantaged group–could be met even if the gap between least and most advantaged groups worsened, just so long as there was a large improvement in the most disadvantaged group.

If the policy goal is to narrow the gap between the lowest and highest socio-economic group, then the strategy might be to focus efforts in the lowest socio-economic group to the exclusion of other groups. Because targeted interventions use more resources per person reached than population-wide interventions, theoretically a reduction in health gap could occur even though a smaller number of people, including a smaller number of disadvantaged people, achieved a health gain.

If the goal is to reduce the social gradient for tobacco use, then the best strategy will be to focus efforts on the most disadvantaged 40 to 50% of the population, even if this means somewhat less change among the most highly disadvantaged 10 to 20% than could be achieved if the goal was to narrow the gap between the highest and lowest groups.

9.0.2.3 Absolute and relative changes in inequality

To assess progress in reducing tobacco-related health disparities it is necessary to monitor trends in tobacco use across social groups defined in a consistent way across time.

Trends in inequality can be expressed in absolute terms (for instance, the size of the decrease from one time to another in the proportion of people who smoke in one group compared with another), or in relative terms (for instance, the extent to which the proportional difference in smoking rates between high and low groups increases or declines over time.²²

9.0.2.4 Apparent change versus statistically significant change

Sample sizes of surveys used to quantify smoking-related beliefs and behaviour in Australia are generally not very large, particularly compared with similar studies undertaken in the US. Differences between groups and year-on-year changes are often quite small and wide confidence intervals surround estimates relevant to particular social groups in particular years. To assess whether absolute and relative differences and changes among various groups are significant or whether they could be due merely to chance, researchers often need to aggregate data over several years or aggregate subjects into a smaller number of groups (for instance high, medium and low income groups rather than income quintiles) to ensure reasonable sample sizes and to apply appropriate statistical tests.

9.0.3 Data available on tobacco-related disparities in Australia

Data about smoking and socio-economic status in Australia can be drawn from several different ongoing surveys.

The Australian Government Department of Health and Ageing has collected data periodically since 1985 to assess the impact of the National Campaign Against Drug Abuse, later renamed the National Drug Strategy.

Since 1998, the Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Survey has collected data every three years from almost 30 000 people aged 14 years and older^iv who provided information on their drug use patterns, attitudes and behaviours.^23–26 The sample is based on households, so homeless and institutionalised people are not included^v. Respondents are asked a number of questions that enable researchers to classify their smoking status. They are also asked about recency of last cigarette and numbers of cigarettes smoked each day or weekly. Similar information was collected in national surveys conducted for the Anti-Cancer Council of Victoria^vi for adults 16 years and over in 1974²⁷ and 1977²⁸ and then every three years until 1998.^{vii 29–35} Chapter 1 presents data from both these surveys re-analysed to cover consistent age groups (18 years and over), with adjustments for slightly different classifications of socio-economic status.

The Australian Bureau of Statistics' National Health Survey collected data in 1989–90,³⁶ 1995,³⁷ 2001,³⁸ 2004–05³⁹ and 2007–08⁴⁰ from Australians 18 years and over.^viii It provides data on smoking status as well as other risk factors, disability, recent health episodes and chronic health conditions,⁴¹ and data are available about smoking rates in various educational, occupational and socio-economic status (SES) categories.

In addition, more detailed data about smoking attitudes and behaviour among various SES groups are available in a number of states from surveys conducted for health departments, and from surveys conducted at research centres based at the Victorian⁴² and South Australian⁴³ cancer councils. The cancer council data and data collected by the Department of Health and Ageing to assess the impact of the National Tobacco Campaign⁴⁴ provide information about smoking status and estimated number of cigarettes smoked per day. These and the Australian arm of the International Tobacco Control Policy Evaluation Study^{45, 46} also provide a wealth of information about smokers, including factors such as: psychological profiles and social environment, awareness and understanding of health effects, awareness of campaigns, the impact of policy interventions, past quit attempts and future intentions to quit.

The Household Income and Labour Dynamics in Australia survey conducted by the Melbourne Institute of Applied Economics and Social Research collects data on smoking status and financial stress among a panel of individuals over a period of time during which they may face changes in household employment status, housing, occupation and income.⁴⁷

In contrast to these surveys asking directly about smoking, the Australian Bureau of Statistics Household Expenditure Survey provides interesting data about spending on tobacco products among various household types.⁴⁸

In Australia, surveys of smoking behaviour by secondary school students co-ordinated by Cancer Council Victoria and conducted every three years since 1984 do not ask about the socio-economic status of students' families. However, analysis of the level of disadvantage of the area in which the student resides provides some indication of trends in uptake by socio-economic status.^{49, 50}