In Australia, reducing socio-economic disparities in smoking is a high priority for tobacco control policy units, health promotion organisations, and social marketing campaigns.
One of the key priority areas of Australia’s 2012–18 National Tobacco Strategy is strengthening efforts to reduce smoking among populations with a high prevalence of smoking. It outlines a number of aims to achieve this, including population-based approaches such as social marketing campaigns, tax increases, and smokefree legislation, as well as ensuring access to individual cessation support.1 Reducing disparities and disadvantage is also subject of state-based tobacco control initiatives, such as the Cancer Council NSW Tackling Tobacco Program.2 The Victorian Health Promotion Foundation (VicHealth) has developed a framework as part of its Fair Foundations program that provides policy makers and practitioners with practical, evidence-based guidance on reducing inequities in health caused by tobacco use.3 Reducing smoking among disadvantaged groups is also a key priority for Quit Victoria.4
The following sections present information on the effects of population-wide strategies and targeted interventions on disadvantaged groups and on tobacco-related disparities.
9.10.1 Effectiveness of population strategies with disadvantaged groups
A number of evidence reviews have concluded that population-wide tobacco control policies, such as smokefree legislation, restrictions on sales to minors, bans on advertising and promotion, and graphic health warnings are at least as effective among low-socioeconomic status (SES) as high-SES groups,5-7 and may serve to reduce inequalities in smoking.8, 9 Price increases and high levels of tobacco taxation appear to be particularly effective in reducing prevalence among disadvantaged groups, and in turn reducing tobacco-related disparities.5, 6, 10
The potential for further progress with each of these strategies in Australia is discussed below.
188.8.131.52 Taxation to reduce the affordability of tobacco products
Before April 2010, excise and customs duty on tobacco products had not increased in real terms in Australia since November 1999. On 30 April 2010, the Australian Government raised the excise on tobacco products by 25%, making Australian cigarettes among the least affordable in the world (see Section 13.2) . In 2013, the prevalence of regular smoking was significantly lower than in 2010 in all socioeconomic groups (except the middle group, which only approached significance). The largest increase in never smokers was in the most disadvantaged group (see Section 9.2 ). Among all smokers in 2013, ‘it was costing too much’ was the most commonly cited reason for changing their smoking behaviour.11
In 2013, the Government introduced an annual increase of 12.5% in tobacco excise over the subsequent four years, the last of which came into effect on the 1st of September 2016.12
Pricing and taxation is among the most effective tobacco control strategy, particularly among disadvantaged groups. Australian research shows that tobacco tax increases have had a substantial impact on smoking prevalence in low socio-economic groups,10, 13, 14 and similar results have been found internationally.5, 6
Analysis of data from the International Tobacco Control Policy Evaluation (ITC) Four-country survey suggests that while behaviours to avoid high prices and tax on tobacco products are common across all socio-economic groups, low-SES smokers in the UK, Canada, Australia and the US are on average 25% more likely to engage in one or more behaviours to avoid or minimise paying tax on tobacco products compared to those of higher socio-economic status. For example, those in the low-SES group were 85% more likely than high-SES respondents to use discount brands or roll-your-own (RYO) cigarettes. Higher socio-economic groups in comparison were more likely to report traveling to an area of low-tax, purchasing tobacco duty-free or purchasing in cartons rather than individual packs. Given the findings of the analysis, the researchers concluded that reducing price differentials between discount and premium brands may have a greater impact on low-SES smokers.15
For a further detailed discussion on tobacco price and impacts on low socio-economic groups, see Chapter 13, Section 13.11.
184.108.40.206 Smokefree policies
Smokefree workplace policies reduce the amount of tobacco smoked, reduce exposure to secondhand smoke, increase rates of quitting, and reduce the chance of a quitter relapsing. 16
All Australian states and territories have now implemented bans on smoking in enclosed workplaces, including in hospitality venues (see Chapter 15 ). The extension of smokefree policies from restaurants to pubs in Victoria had a more profound impact on smokers in the lower socio-economic group, with 40% reporting smoking less after the introduction of the ban, compared to 24% in the higher socio-economic group.17
Many Australian states and territories have extended smokefree policies to cars carrying children, and to outdoor areas, such as playgrounds and outdoor dining areas (see Section 15.7 ). Such policies have the potential to reduce socioeconomic disparities in smoking prevalence18 and health outcomes.19 National, comprehensive smokefree policies are more effective at reducing inequities than voluntary, regional, and partial policies.20
People on lower incomes are more likely to allow smoking inside their home (see Section 9.1 ). Government tobacco control policies appear to have positive flow-on effects for the adoption of smokefree policies in people’s homes, with European research finding a positive association between the strength of national policies and in-home smoking bans.21 The increasing introduction of smokefree policies in apartment buildings may also be particularly effective in reducing secondhand smoke exposure among disadvantaged groups.22
220.127.116.11 Pictorial health warnings
Pictorial health warnings appear to be at least as effective among disadvantaged as more advantaged smokers,5, 20 and are more effective than text-only warnings.23 This may be due to a greater ease of understanding, as well as their emotionally evocative content, which is a particularly effective strategy among disadvantaged groups.23
Results from the International Tobacco Control Four-country Survey showed that pictorial health warnings introduced in Australia in 2006 were noticed more frequently among less educated smokers than among smokers with a university education (see Figure 9.10.1).
Percentage of smokers rarely and frequently reading new pictorial health warnings on cigarette packets, smokers 18 years and over, Australia 2006, by level of educational attainment
Source: Data file of responses to the fifth wave of the International Tobacco Control Four-country Survey, by educational attainment and income adjusted for household size, provided to Michelle Scollo of the Tobacco Control Unit, Cancer Council Victoria, by J Cooper and R Borland Cancer Council Victoria, 2008.
The proportion of smokers who noticed the new warnings often or very often was 10% higher among those who had not finished high school than among those smokers with a university education. While low-SES smokers were no more likely than high-SES smokers to report thinking about the harms of smoking as a result of looking at the warnings, they were more likely to report forgoing cigarettes. Graphic warnings may therefore be somewhat more effective among lower than higher SES groups in prompting quitting behaviours. Data from Wave 8 (July 2010–May 2011) of the International Tobacco Control (ITC) Four-country Survey show that, although less pronounced, those with lower education levels were still slightly more likely to report noticing the health warnings often or very often (see Figure 9.10.2).
Percentage of smokers reporting reading or looking closely at the health warnings on cigarette packets in the past month, smokers 18 years and over, Australia, July 2010–May 2011, by educational attainment
Source: Data file of responses 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.
Since the 1st of December 2012, cigarette packs sold in Australia must be drab, dark brown in colour and devoid of all brand design, and must carry larger, graphic health warnings (see Section 11.10 ). An experimental study prior to implementation of plain packaging found that plain packs were rated as significantly less appealing than branded packs among socioeconomically disadvantaged smokers, and such packs also reduced purchase intentions.24 Research post-implementation among Indigenous Australians found that plain packaging had reduced misperceptions that some brands are healthier than others. Compared with pre-plain packaging, younger Indigenous Australians were less likely to view some brands as more prestigious than others.25
18.104.22.168 Under-the-counter sales of cigarettes
The display, advertising, and accessibility of tobacco products in retail outlets are associated with uptake, smoking, and relapse.26-28 While all Australian states and territories have banned tobacco marketing and display in retail outlets, such restrictions do not reduce the availability of tobacco products. There is a clear inverse association between SES and tobacco retailer density, such that the density of tobacco outlets tends to be higher in areas with lower average incomes.29, 30 This has led to calls for policy that would reduce/limit the number of tobacco retail outlets. See Section 11.9 for a detailed discussion.
22.214.171.124 More effective use of mass media
There is strong evidence that exposure to mass media campaigns reduces tobacco uptake and promotes quitting.31 Quit Campaigns in Australia have targeted media placement (both in terms of timing and program and program type) and pre-tested advertisements among low-SES groups to ensure that they are equally effective among such groups.32-37
A 2012 review of the effects of mass media campaigns on smoking cessation concluded that higher exposure appears to confer greater benefit on socioeconomically disadvantaged population subgroups, particularly messages that portray the negative health effects of smoking.38 Emotionally evocative ads, and ads that contain personal stories about the effects of smoking and quitting, appear to be particularly effective among lower income groups.39, 40 Such ads may be more effective for low-SES groups because they do not rely on explicit arguments or information (which require assessment of the merits of the message, and acceptance of the argument/message).41-43 Further, messages that are personally relevant and emotionally engaging are more likely to increase perceptions of susceptibility to health risks and be discussed with others.44, 45
126.96.36.199 Harm reduction: a strategy of benefit for disadvantaged groups?
Disadvantaged smokers tend to smoke more heavily, be more highly dependent on nicotine, and be less successful at quitting.46, 47 For smokers who are unwilling or unable to quit, harm reduction—through regulatory approaches such as reducing the harmfulness of cigarettes or individual approaches such as switching to alternative products that may carry fewer risks than traditional cigarettes—has been suggested as an alternative to complete cessation. See Chapter 18 for a full discussion.
9.10.2 Encouraging greater utilisation by disadvantaged groups of cessation treatment and services demonstrated to be effective
Apart from the application of the population-level strategies listed above, encouraging better use of existing services and treatments by low-SES groups also holds promise for reducing inequalities. Encouraging Victorian data shows that low-SES smokers are just as likely to prioritise quitting and to phone the Quitline, and more likely to seek out online cessation information, as high-SES smokers.48
The most effective form of cessation support is a combination of behavioural interventions (such as counselling) and pharmacotherapy (such as NRT or cessation medications).49, 50 The development of targeted interventions that address smoking among low-SES groups is a high clinical and economic priority to reduce health inequalities and improve life expectancies,51 and to reduce the financial burden of smoking.52 However, there has traditionally been a lack of research into the effectiveness of such interventions among different social groups.53 A systematic review of research over the past decade into cessation among low-SES and other disadvantaged groups concluded that the current research output is not ideal or optimal to decrease smoking rates.51 Nonetheless, recent research has attempted to develop and tailor interventions to reduce smoking among low-income groups. See Chapter 7, Section 7.19 for an overview of cessation interventions for low-income, homeless, and other priority groups.
The ‘Tackling Tobacco’ initiative undertaken by the Cancer Council NSW aims to encourage and support non-government social and community services to address smoking among their clients. An evaluation of program results ‘challenged assumptions and attitudes that disadvantaged people are uninterested or unable to quit’. Clients of these organisations were receptive to receiving quitting support from the trained staff in these services, and the staff providing this care report knowledge and confidence in addressing tobacco among their clients. The program results also indicate improvement in quality of life among clients who do quit smoking.54
9.10.3 Preventing uptake among disadvantaged children
Along with increasing rates of cessation, preventing uptake among disadvantaged children forms an important part of reducing disparities in smoking prevalence. Encouragingly, over the 2000s, smoking rates have reduced among Australian school students across all socioeconomic groups, and generally show a convergence in prevalence (see Section 9.2).
Higher cigarette prices reduce smoking both among youth55 and among people from disadvantaged backgrounds.56 Other important factors in preventing youth uptake include denormalising smoking, awareness-raising through education, and ‘de-glamorising’ smoking.57 (see Chapter 5 for a detailed discussion).
Interventions that could balance the factors promoting SES differentials in tobacco use
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