Position statement - Tobacco related disparities

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Position statement - Tobacco related disparities

"There is a lot of death and suffering ahead of us, but it will be concentrated among those already suffering the most"

– Professor Ron Borland[1]

Key messages and recommendations

  • While smoking rates across Australia have declined substantially to around 17.5% of the population, among the most disadvantaged groups they are up to five times higher than the population average.
  • The most disadvantaged groups in Australia bear a disproportionate share of tobacco-related harm. Reducing smoking rates in these populations is an important and pressing public health issue.
  • Sustained population-wide tobacco control strategies must be supported by specific interventions targeting disadvantaged populations in order to maximise reach and effectiveness among these groups.
  • Effective strategies require a combination of applying best current evidence with being open to exploring the effectiveness of new strategies.
  • The development of partnerships between tobacco control public health experts and community-based organisations working with targeted populations will help to develop capacity within these organisations to address specific tobacco-related issues, create quit-friendly service environments and integrate attention to smoking into routine practice.
  • Obtaining better data on smoking prevalence trends among disadvantaged groups and monitoring progress in this space are integral to reducing disparities in tobacco use. It is critically important that interventions are underpinned by financial support for evaluation of appropriateness and effectiveness.

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While much progress has been made in reducing smoking rates in Australia over the past decades, rates of smoking remain high among people facing multiple disadvantage and challenges. The most disadvantaged groups in Australia include people who, in addition to low income, face a number of other difficulties such as mental illness, sole parenthood, unemployment, domestic violence, homelessness, drug and alcohol problems, criminal justice issues, limited education, and social isolation. These issues often overlap and their effects are compounded.

Smoking rates across Australia have declined substantially to around 17.5% of adults smoking weekly or more often[2], however among the most disadvantaged groups smoking rates are up to five times higher than the population average[3]. A range of Australian studies indicate high smoking rates among groups such as: single parents (37%)[2], lone mothers 18–29 years of age (59%)[4], people living with psychosis (66%)[5], at-risk young people (63%)[6], Aboriginal and Torres Strait Islander peoples (47%)[7], people with drug disorders (73%)[8], the homeless (73%)[9], intravenous drug users (90%)[3], and prisoners (85%)[10]. Many of the most disadvantaged smokers will belong to more than one of these groups.

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Links between smoking and disadvantage

Disadvantage is associated with smoking; increased disadvantage is associated with increased smoking prevalence[11].

Many factors across the life course can combine to embed smoking in the lives of disadvantaged people[12][13]. Research has shown that individual dimensions of disadvantage contribute independently to the likelihood of being a smoker and to reduce the odds of quitting. For example, women in the UK were at increased odds of being a heavy smoker if they experienced childhood disadvantage, left school aged 16 or less, were a mother at age 22 or younger, or if they experienced severe disadvantage as an adult[13].

In addition the relationship between smoking and disadvantage has been shown to be cumulative, that is as the number of experiences of disadvantage accrue smoking rates increase[11][13][14]. Table 1 maps this association between disadvantage trajectories and smoking status.

Table 1. Cumulative disadvantage and smoking status

Sample Number Ever smoked
Current smoker
Heavy smoker
(% of current smokers)
Former smoker
(% of ever smokers)
Childhood disadvantage 3800 51.6 35.9 49.6 30.4
Plus left full time education ≤ 16 2081 61 44.1 53.3 27.7
Plus a mother at age ≤ 22 744 70.3 54.6 57.1 22.4
Plus adult disadvantage 405 75.6 62.5 56.1 17.3
None of these disadvantages 3614 33.3 18.3 34.5 45.1

This table describes smoking rates in women, aged 22-34, England, 1998-2002, n=9936. Each row denotes cumulative disadvantage, incorporating the dimension(s) of disadvantage in the rows above.
Source: Adapted from Graham et al. 2006[13]

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Tobacco burden among disadvantaged populations

The additional burdens imposed by smoking are felt most keenly by those already experiencing disadvantage. Those who are already disadvantaged already bear a disproportionate share of the burden of death and disease caused by tobacco[15][16]. Furthermore, the differentials in smoking rates contribute to widening health, financial and quality of life inequities in our community[12][17][18].

Smoking is a major contributor to the differences in mortality between the least and most advantaged[19]. International research has shown that smoking accounts for more than half the difference in mortality between men in the top and bottom social strata[19]. Disparities in health status between Indigenous Australians and the total population account for 59% of the total burden of disease for Indigenous Australians[20]. Smoking accounts for 17% of this health gap, making it the primary risk factor contributing to health disparities in Indigenous Australians[20]. Unless we address smoking disparities, health inequality will persist[21].

In addition to health impacts, tobacco contributes to poverty and disadvantage through the cost of tobacco-related illness, loss of family breadwinner, impact on family stress and finances, and the impact on children’s education and employment opportunities[22]. Spending on tobacco products, school absence and loss of income due to smoking-related illness reduces the capacity of a household to accumulate assets such as a family home, to insure against losses, to save for financial requirements in retirement and to pass on assets to the next generation, contributing to financial inequalities further[23].

Tobacco exacerbates the impact of poverty by reducing funds available to cover food, clothing and stable housing[24][25][26][27]. Households that smoke are three times more likely to experience severe financial stress and report going without meals and being unable to heat the home than non-smoking households[28]. Children in smoking households are twice as likely to experience food insecurity and three times as likely to experience severe food insecurity than children in non-smoking households[25]. In the lowest-income households, expenditure on tobacco products as a proportion of total household weekly expenditure is over double that in the highest income households[29].

In addition, higher smoking prevalence among adults in lower socio-economic families is associated with higher uptake of smoking among children from these families[22]. This continues the cycle of financial stress and ill health from tobacco use into the next generation.

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Environmental drivers

Disadvantaged groups experience multiple drivers to smoke and magnified barriers to quitting. People from disadvantaged groups are more likely to be in environments where smoking is the norm and where little support is provided for quit attempts[18]. Compared to others in the community, they are more likely to be around others who smoke, smoke a greater number of cigarettes and smoke for longer periods of time[26][30].

Smoking can be used as a coping mechanism among the lives of people experiencing multiple disadvantage. It is often seen to help deal with difficult and stressful situations such as financial pressure, living in unsafe environments, being a single parent, and limited opportunities for enjoyment and recreation[31][32][33].

A range of factors reinforce smoking and present barriers to quitting in people facing multiple disadvantage, including:

  • heavier nicotine dependence[12];
  • experiencing financial stress[26];
  • having friends and family who smoke and living in communities with a high prevalence of smoking[34][35];
  • facing multiple daily stressors for which smoking is seen as a means of coping[32];
  • lack of support for quitting among family and friends[30][34];
  • being unaware of, or having misconceptions about, available cessation services[31][36];
  • lower levels of confidence in their ability to stop smoking[37];
  • regarding smoking as their ‘only pleasure’[32][34][38]; and
  • specific marketing by tobacco companies[39][40][41].

While all smokers may experience these factors to some extent, their impact is magnified for the most disadvantaged. Given their collective impact, these factors suggest disadvantaged smokers may need greater support to quit than those people experiencing less disadvantage[42]. Disadvantaged smokers are as interested in quitting as other smokers, but are less likely to succeed without further assistance[43][44][45].

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Effective strategies targeting disadvantaged groups

A combination of strategies is required to effectively reduce smoking among the most disadvantaged population groups. Established whole-of-population approaches must be coupled with targeted strategies and emerging promising approaches to reach these groups.

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Population-wide strategies

Research demonstrates that tobacco price increases[46][47][48], advertisements containing highly emotional elements or personal stories[49], increasing the level of TV advertising[50], and the extension of smoke-free policies from restaurants to pubs[51] are reported to have a strong impact on smokers in lower socio-economic groups, resulting in reductions in tobacco use and increased calls to Quitline. Importantly, population-wide strategies reduce uptake and experimentation of smoking among all adolescents, but in particular adolescents from low socio-economic groups. During a period of low tobacco-control funding and activity (1992–1996) smoking prevalence increased among 12–15 year olds, with the greatest increase among lower socio-economic groups[52].

While population-based tobacco control approaches have demonstrated effectiveness among smokers from low socio-economic groups, there is increasing recognition that more targeted strategies are required to reach the most disadvantaged population groups.

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Community-based interventions

Research shows that integrating smoking cessation support in social and community organisations already working with disadvantaged groups has been effective in decreasing smoking rates[53][54]. Social and community service organisations have regular and long-term contact with clients, concern for client wellbeing, and skills in supporting behavioural change which make them well suited to provide smoking cessation to their clients[30][55][56][57]. Recommended approaches include reviewing and revising organisational policies, supporting staff to quit, changing practices to de-normalise smoking, making more active quit support for clients part of routine care, and changing systems to record and monitor smoking status[58]. This approach should be applied within both non-government and government social and community services whose clients have high smoking rates, such as prisons, mental health facilities, drug and alcohol services, family services, and homeless shelters[34].

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Improving access to cessation aids

Encouraging better use of existing services and treatments by low income groups shows potential for reducing tobacco related inequalities.

Quitting medications are effective in smokers with high nicotine dependence and when subsided or free, are increasingly used by disadvantaged smokers[59][60]. Evidence demonstrates that the chances of quitting successfully are increased when using quitting medications in combination with a quit counselling service[61]. However, both the cost and the time it takes to access subsidised pharmacotherapies can act as an obstacle to their use by the most disadvantaged[30][31][62]. Alternative systems, such as provision of free Nicotine Replacement Therapy directly through social and community services, or pharmacists, should be explored.

Encouraging better use of existing quit services can be achieved through promoting direct referrals from social and community organisations and delivering cessation support that is sensitive to the diverse needs of different population groups. For example, people from disadvantaged groups have expressed that they want information and practical support to quit smoking but want it delivered in a way that recognises the role of smoking in their lives and in the other issues they are facing[32][35]. Key elements of effective cessation approaches with disadvantaged population groups include: a non-judgemental, holistic and empowering approach; provision of social support; flexibility and accessibility; and well trained staff[63].

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Utilising financial incentives

There is growing evidence for incentive-based programs in the UK and US as a way to change unhealthy behaviours including smoking[64]. Financial incentives have been used in smoking cessation initiatives to encourage participation and to support the quitting process including rewarding cessation[65][66].

Research shows high acceptance of monetary and non-monetary rewards as a smoking cessation strategy among disadvantaged groups[67][68][69], that financial incentives rewarding participation increase recruitment rates (which may in turn be expected to deliver higher numbers of successful quitters)[65][70], and has increased quit rates among pregnant women in disadvantaged groups (increasing abstinence more than three-fold)[66].

Reviews conclude that financial incentives can be effective in promoting behaviour change (i.e. prompting people to quit smoking and to use evidence-based treatment). Further research is required to develop the evidence base in relation to long-term cessation and the practicalities of implementing financial incentives[64][65][70].

Other areas to explore further include: how to implement financial incentive schemes for promoting smoking cessation within the Australian context, the merits of cash payments versus payments in kind (e.g. grocery vouchers), the most effective type and size of incentives, maintaining incentives to achieve cessation in the long term, and efficacy in different population groups[65][70].

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Supporting social and economic policies

Macro level policies that reduce poverty, enhance family functioning, reduce childhood adversity, improve housing, provide access to quality education and provide access to stable employment have an impact on smoking prevalence as they reduce the negative social conditions that are associated with higher smoking rates and dependence[13][71][72]. Leaders in tobacco control and public health should work together with those in the community sector calling for progressive social policies.

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Building the evidence

It is important to note current surveys and monitoring tools are not adequately capturing or monitoring smoking rates in disadvantaged populations in Australia and trend data is not routinely collected for these groups. Population based surveys do not capture, for example, people who are homeless, without phone access, who are living in mental health facilities, or who are mentally or physically unable to respond to surveys. Although there is a growing body of smoking prevalence data available for specific disadvantaged groups, this information is often incomplete and discontinuous. Improvements in our data collection systems are required to establish reliable prevalence and to measure prevalence rates over time and could be achieved by adding to existing surveillance tools and mining other databases that are currently underutilised.

Investment in research and evaluation is essential to monitor the impact of our strategies and to add to the evidence base. There are complexities in devising and delivering programs that effectively address smoking among disadvantaged groups. Therefore it is critical that programs include mechanisms to evaluate and assess their effect.

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The serious health, social and financial harm caused by smoking among our most disadvantaged population groups cannot be ignored. The disparities in smoking rates within the community must be considered a social justice issue[18]. Reducing smoking among disadvantaged populations should be a priority. To achieve this goal Cancer Council Australia recommends investment in a range of strategies including:

  • maintenance of ‘whole of population’ approaches to reduce uptake and encourage cessation such as legislation and regulation, limiting access to tobacco, increased taxation, and comprehensive and sustained mass media campaigns;
  • the introduction of comprehensive policies to address smoking and active quit support for clients and staff within government and non-government social and community services working with disadvantaged populations;
  • improved access to quit counselling and affordable pharmacotherapies including all types of Nicotine Replacement Therapy;
  • investigating the effectiveness and practicality of financial incentives in promoting smoking cessation in disadvantaged groups;
  • adoption of progressive social policies to reduce the social inequalities in which smoking disparities are embedded; and
  • investment in appropriate research and evaluation to build the evidence base around what works in addressing tobacco in disadvantaged populations. This includes investment in improved monitoring and surveillance of smoking prevalence, analysis of disparities between population groups and continued exploration for new strategies.

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