9.0 Introduction

Last updated: February 2023
Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.0 Introduction. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-0-introduction

 

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

As with many other high-risk behaviours, the prevalence of smoking is significantly higher among disadvantaged groups and is one of the major factors driving their generally poorer health status. Spending on tobacco products and ill-health contribute significantly to financial stress, and can hinder the accumulation of household savings and assets, perpetuating intergenerational poverty. Financial stress and poverty create social conditions that may make it more difficult to successfully quit smoking, and continued high levels of tobacco use by parents and peers powerfully models smoking, thus perpetuating continuing high levels within neighbourhoods and across generations. Further, the substantially higher rates of smoking among disadvantaged pregnant women has far-reaching effects on the short- and long-term health of their children.

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 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 area is also often regarded as an indicator 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 three tertiles, 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.1

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.

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

  • the Index of Advantage\Disadvantage, which is a continuum of advantage to disadvantage
  • an Index of Economic Resources, which includes rent paid, income by family type, mortgage payments, and rental properties and
  • an Index of Education and Occupation.1,2

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 today 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;3 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.

One of the priority areas of Australia’s 2022–2030 draft National Tobacco Strategy is strengthening efforts to prevent and reduce tobacco use among populations at a higher risk of harm from tobacco use and populations with a high prevalence of tobacco use. It outlines a number of actions to achieve this, including targeted policies, programs and investments; building the evidence base to identify cost-effective approaches; increasing awareness of evidence-based support to quit; implementing prevention and cessation programs as part of routine care across all health, social care and custodial settings; embedding cessation programs across all health care settings; strengthening collaboration and referral between health services, social services, custodial organisations and tobacco cessation services; enhancing Quitline services for priority populations; and considering the feasibility of introducing a Census question on tobacco and e-cigarette use.4  

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.5 , 6 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 use5
    • 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.7 ,8

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 widened, 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 10–20% 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 to 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.9 

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—see Sections 9.1 and 9.2.

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 who provided information on their drug use patterns, attitudes and behaviours.10 The sample is based on households, so homeless and institutionalised people are not included (see InDepth 9A for estimates of smoking prevalence among people experiencing homelessness or incarceration, and other priority populations in Australia). Respondents are asked a number of questions about their smoking and e-cigarette use. Data on smoking was collected in national surveys conducted for the Anti-Cancer Council of Victoria (now Cancer Council Victoria) for adults 16 years and over in 197411 and 197712 and then every three years until 1998.13-19

The Australian Bureau of Statistics’ National Health Survey collected data in 1989–90,20 1995,21 2001,22 2004–05,23 2007–08,24 2011–12,25 2014–15,26 2017–18,27 and 2021–2228 from Australians 18 years and over. It provides data on smoking status as well as other risk factors, disability, recent health episodes and chronic health conditions,29 and data are available about smoking rates in various educational, occupational, and socio-economic status (SES) categories.

In addition, more detailed data about smoking among various SES groups are available in a number of state-based surveys,30,31 as well as the Australian arm of the International Tobacco Control Policy Evaluation Study.32 These surveys provide a wealth of information about people who smoke, 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.33

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 types34 —see Section 9.4.

In Australia, surveys of smoking behaviour by secondary school students coordinated 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 status35-38 —see Section 9.2.4.

Relevant news and research

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References

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