Tobacco in Australia Facts & Issues A comprehensive online resource
tobaccoinaustralia.org.au Book excerpt
List of chapters available at tobaccoinaustralia.org.au Introduction Chapter 1 Trends in the prevalence of smoking Chapter 2 Trends in tobacco consumption Chapter 3 The health effects of active smoking Chapter 4 The health effects of secondhand smoke Chapter 5 Factors influencing the uptake and prevention of smoking Chapter 6 Addiction Chapter 7 Smoking cessation Chapter 8 Tobacco use among Aboriginal peoples and Torres Strait Islanders Chapter 9 Smoking and social disadvantage Chapter 10 The tobacco industry in Australian society Chapter 11 Tobacco advertising and promotion Chapter 12 The construction and labelling of Australian cigarettes Chapter 13 The pricing and taxation of tobacco products in Australia Chapter 14 Social marketing and public education campaigns Chapter 15 Smokefree environments Chapter 16 Tobacco litigation in Australia Chapter 17 The economics of tobacco control Chapter 18 The WHO Framework Convention on Tobacco Control Appendix 1 Useful weblinks to tobacco resources
Tobacco in Australia: Facts and Issues. Fourth Edition A comprehensive review of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria. First edition published by ASH (Australia) Limited, Surry Hills, NSW, 1989 Second edition published by the Victorian Smoking and Health Program, Carlton South, Victoria (Quit Victoria), 1995 Third edition published by Cancer Council Victoria 2008 in electronic format only. ISBN number: 978-0-947283-76-6 Suggested citation: Scollo, MM and Winstanley, MH. Tobacco in Australia: Facts and issues. 4th edn. Melbourne: Cancer Council Victoria; 2012. Available from www.TobaccoInAustralia.org.au OR
Chapter 9 Smoking and social disadvantage Chapter 9: Smoking and social disadvantage i Chapter 9 Smoking and social disadvantage
By Michelle Scollo, Table of contents VicHealth Centre for Tobacco Control with 9.0 Introduction...... 1 input from Dr Mohammad 9.0.1 What is social disadvantage?...... 1 9.0.2 What is health inequality?...... 2 Siahpush, formerly Centre 9.0.2.1 Tobacco-related disparities...... 3 for Behavioural Research 9.0.2.2 Inequality as deficit, gap or gradient...... 3 in Cancer, Cancer Council 9.0.2.3 Absolute and relative changes in inequality...... 4 Victoria, now Professor, 9.0.2.4 Apparent change versus statistically significant Department of Health change...... 4 Promotion, Social and 9.0.3 Data available on tobacco-related disparities in Australia...... 4 Behavioral Health, College of 9.1 Socio-economic position and disparities in tobacco exposure Public Health, University of ...... 8 and use Nebraska Medical Center 9.1.1 Disparities in smoking during pregnancy...... 8 9.1.2 Disparities in exposure of children to secondhand smoke...... 8 Updated by Merryn Pearce, 9.1.3 Disparities in smoking behaviours among young people...... 9 9.1.4 Disparities in smoking prevalence among adults...... 10 Policy Unit, Quit Victoria 9.1.5 Disparities in reported cigarette consumption...... 11 9.1.6 Disparities in duration of smoking...... 11 9.1.7 Disparities in exposure to secondhand smoke...... 12 9.1.7.1 Disparities in workplace exposure...... 12 9.1.7.2 Disparities in domestic exposure...... 12 9.1.7.3 Exposure in institutional settings...... 13
9.2 Socio-economic disparities in tobacco exposure and use: are the gaps widening?...... 16 9.2.1 Changes in the prevalence of smoking among adults in various socio-economic groups...... 16 9.2.1.1 Changes in prevalence among those with varying levels of formal education...... 17
Date of last update: 20 November 2012 Tobacco in Australia: ii Facts and Issues
9.2.1.2 Changes in prevalence in blue versus white collar groups...... 18 9.2.1.3 Changes in smoking prevalence by area-level measures of SES...... 19 9.2.2 Differential uptake or differential cessation?...... 21 9.2.3 Changes in consumption of cigarettes...... 25 9.2.4 Changes in the prevalence of smoking among students in schools in areas of varying levels of disadvantage...... 26 9.2.5 Changes in childhood exposure to smoking in the household...... 27 9.2.6 International comparisons...... 27
9.3 Contribution of smoking to health inequality...... 30 9.3.1 Socio-economic position, reported health status and smoking...... 30 9.3.2 Socio-economic position and illnesses known to be caused by smoking...... 30 9.3.3 Socio-economic disparities in death rates from diseases known to be caused by smoking...... 31 9.3.4 Socio-economic disparities in health-adjusted life expectancy...... 32 9.3.5 Quantifying the contribution of smoking to socio-economic differentials in health status...... 33 9.3.6 Are tobacco-related differentials in health status widening?...... 34
9.4 The relationship between tobacco smoking and financial stress...... 38 9.4.1 Spending on tobacco as a cause of financial stress...... 38 9.4.2 Financial stress and its influence on smoking abstinence...... 39 9.4.3 Smoking cessation and the reduction of financial stress...... 39
9.5 Smoking and intergenerational poverty...... 41 9.5.1 Spending on tobacco products and its impact on financial security and wealth accumulation...... 41 9.5.2 The long-term effects of smoking during pregnancy...... 42 9.5.3 Exposure to environmental tobacco smoke and school absence...... 42 9.5.4 Parental example and smoking uptake: the cycle continues...... 43
9.6 Smoking, ill-health, financial stress and smoking-related poverty among highly disadvantaged groups...... 46 9.6.1 People living in regional and remote areas of Australia...... 46 9.6.2 People born overseas...... 47 9.6.3 Lone parents, especially lone mothers...... 49 9.6.4 People with mental illnesses...... 51 9.6.4.1 Mental illness and disadvantage...... 51 9.6.4.2 Smoking among those with long-term mental health or behavioural problems...... 51 9.6.4.3 Smoking among those with serious psychiatric illnesses...... 51
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9.6.4.4 Financial stress among those with mental illness who smoke...... 52 9.6.4.5 Preventable diseases among those with mental illness who smoke...... 53 9.6.4.6 Barriers to cessation among those with mental illness...... 53 9.6.5 People with alcohol and drug problems...... 53 9.6.6 The homeless...... 54 9.6.7 Prison populations...... 54 9.6.8 Veterans...... 55 9.6.9 Indigenous communities...... 56 9.6.10 Vulnerable youth...... 56
9.7 Explanations of socio-economic disparities in smoking...... 63
9.8 Are current strategies to discourage smoking in Australia inequitable?...... 67 9.8.1 Impact of mass media...... 67 9.8.1.1 Impact of mass media in reducing disparities in smoking-related knowledge...... 68 9.8.1.2 Impact of mass media led campaigns across socio-economic groups in Australia...... 69 9.8.2 Differential impact of price increases on low-income groups in Australia...... 69 9.8.3 Differential impact of campaigns and price increases on disadvantaged children in Australia...... 69 9.8.4 Differential impact of smokefree policies...... 70
9.9 Are there inequalities in access to and use of treatment for dependence on tobacco-delivered nicotine?...... 72 9.9.1 Quitlines...... 72 9.9.2 Disparities in use of treatments for tobacco dependence...... 73 9.9.2.1 Disparities in use of treatments...... 73 9.9.2.2 Disparities in compliance with treatment...... 74 9.9.3 Disparities in provision of quit smoking advice and referral by general practitioners...... 75
9.10 Further initiatives to reduce tobacco-related disparities in Australia...... 77 9.10.1 Effectiveness of population strategies with disadvantaged groups...... 77 9.10.1.1 Taxation to reduce the affordability of tobacco products...... 78 9.10.1.2 Smokefree policies...... 78 9.10.1.3 Pictorial health warnings...... 79 9.10.1.4 Under-the-counter sales of cigarettes...... 80 9.10.1.5 More effective use of mass media...... 80 9.10.1.7 Harm reduction: a strategy of benefit for disadvantaged groups?...... 81
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9.10.2 Encouraging greater utilisation by disadvantaged groups of cessation treatment and services demonstrated to be effective...... 81 9.10.2.1 Face-to-face counselling services?...... 82 9.10.3 Developing targeted services and approaches for smokers where these are needed...... 82 9.10.4 Promoting educational achievement, mental health and social connectedness...... 83
Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage v Tables and figures
Table 9.1.1 Percentage of children exposed to smoking in the home, by quintile of disadvantage, Australia, 2010...... 8
Figure 9.1.1 Proportion of monthly smokers among secondary-school students aged 12–15 years by relative socio-economic disadvantage, Australia, 2008...... 9
Figure 9.1.2 Proportion of weekly smokers among secondary school students aged 12–15 and 16–17 years by relative socio-economic disadvantage, Australia, 2008...... 9
Figure 9.1.3 Smoking status by relative social disadvantage, persons 14 years and older, Australia, 2010: never smokers, ex-smokers and current smokers...... 10
Table 9.1.3 Socio-economic characteristics by smoking status, persons 14 years and older, Australia, 2010...... 10
Table 9.1.2 Prevalence of daily smoking, Australians 15 years and over by socio-economic and labour force status, 2007–08...... 10
Table 9.1.5 Mean duration of smoking prior to quitting, Australia, 2001...... 11
Table 9.1.4 Mean number of cigarettes smoked per day, (self-reported) current smokers aged 14 years and older, by social characteristics, by sex, Australia, 2010...... 11
Figure 9.1.4 Proportion of workers reporting a total ban and proportion reporting no restrictions on smoking in their workplace, Australia 1998: blue collar compared to white collar and professional workers...... 12
Figure 9.1.5 Current smokers’ rules about smoking in the home, by annual household income, Australia 2010–11...... 13
Figure 9.1.6 Current smokers’ smoking behaviour around non-smokers in cars, by educational status, Australia 2008–09...... 13
Table 9.2.1 Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment...... 17
Figure 9.2.1 Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment...... 17
Table 9.2.2 Prevalence of regular smokers in Australia aged 18+, 1980–2010: by occupational status...... 18
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Figure 9.2.2 Prevalence of regular smokers in Australia aged 18+, 1980–2010, by occupational status...... 18
Figure 9.2.3 Percentage smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area...... 19
Table 9.2.3 Percentage smokers in Australia and measures of absolute change and relative change, 2001–10, persons aged 18 years and over, by socio-economic index for area...... 19
Table 9.2.4 Percentage smokers in Australia and measures of absolute change and relative change, males aged 18 years and over, 2001–10, by socio-economic index for area...... 20
Table 9.2.5 Percentage smokers in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area...... 20
Figure 9.2.4 Percentage smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area...... 20
Figure 9.2.5 Percentage smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area...... 20
Table 9.2.6 Percentage never smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area...... 21
Figure 9.2.6 Percentage never smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area...... 21
Table 9.2.7 Percentage never smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area...... 22
Figure 9.2.7 Percentage never smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area...... 22
Table 9.2.8 Percentage never smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area...... 23
Table 9.2.9 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, persons 18 years and over, 2001–10, by socio-economic index for area...... 23
Figure 9.2.8 Percentage never smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area...... 23
Figure 9.2.9 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, persons 18 years and over, 2001–10, by socio-economic index for area...... 23
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Table 9.2.10 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, males 18 years and over, 2001–10, by socio-economic index for area...... 24
Figure 9.2.10 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, males 18 years and over, 2001–10, by socio-economic index for area...... 24
Table 9.2.11 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area...... 25
Table 9.2.12 Self-reported cigarettes smoked (number per week) by Australian adult smokers (factory-made cigarettes only), 1980–2010, by occupational class...... 25
Figure 9.2.11 Percentage of ever smokers who have quit in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic index for area...... 25
Figure 9.2.12 Reported current smoking (smoking in the last week), secondary students in Australia aged 16 and 17 years, 1987–2008, ranked by quartiles of advantage by the area in which the student lived...... 26
Figure 9.2.13 Reported current smoking (smoking in the last week), secondary students in Australia aged 12–15 years, 1987–2008, ranked by quartiles of advantage by the area in which the student lived...... 26
Table 9.2.13 Percentage of households who reported smoking only outdoors in the last 12 months, Australia, 2001, 2004, 2007 and 2010, socio-economic index for areas: households with dependent children...... 27
Table 9.3.1 Life expectancy, Australia, 2003, by socio-economic quintile...... 32
Table 9.3.2 Disability-adjusted life years lost, Australia, 2003, by socio-economic quintile, Australia, 2003...... 32
Table 9.4.1 Average weekly expenditure on tobacco products among households in each income quintile, Australia, 2009–10, and as percentage of total household spending...... 38
Figure 9.5.1 Socio-economic influences on cardiovascular disease from a life-course perspective...... 41
Date of last update: 20 November 2012 Tobacco in Australia: viii Facts and Issues
Figure 9.5.2 Proportion of Victorian students aged 12–15 years who were never smokers, experimental smokers or current smokers among students with no parent smoking, one, or two parents smoking, Australia, 2008...... 43
Figure 9.5.3 Proportion of Victorian students aged 16–17 years who were never smokers, experimental smokers or current smokers among students with no parent smoking, one, or two parents smoking, Australia, 2008...... 43
Table 9.6.1 Prevalence of smoking in households containing a child under the age of 15 overall and according to household structure, 2001–10...... 50
Figure 9.7.1 Factors driving socio-economic disparities in smoking uptake...... 64
Figure 9.7.2 Factors driving socio-economic disparities in smoking cessation...... 64
Figure 9.8.1 Proportion of smokers 18 years and over agreeing that smoking causes stroke (subject of TV advertisement) and impotence (subject of newspaper stories but not TV advertising), Australia, 2006, by educational attainment...... 68
Figure 9.8.2 Proportion of smokers 18 years and over agreeing that smoking causes stroke and impotence, Australia, 2010–11, by educational attainment...... 68
Table 9.8.1 Absolute changes in reported smoking prevalence among students aged 12–15 years during high and low periods of tobacco-control activity, Australia, 1987–1990, 1990–1996 and 1996–2005, in schools in various socio-economic status quartiles...... 70
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...... 72
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...... 72
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...... 73
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...... 74
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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...... 74
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...... 75
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...... 79
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...... 79
Figure 9.10.3 Interventions that could balance the factors promoting SES differentials in tobacco use...... 85
Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 1
9.0 Introduction 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: < i For further information on the Index of Disadvantage, see Chapter 6 of National Health Survey: users’ guide – electronic, 2007–08, Australia (cat. no. 4363.0.55.001) and Adhikari 20063 Section: 9.0.1 Date of last update: 20 November 2012 Tobacco in Australia: 2 Facts and Issues Other area-based indexes developed by the Australian Bureau of Statistics include: < 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 theNational 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’ii 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 i The concept of social capital attempts to quantify the resources available to people in the networks in which they live, work and socialise.4 Efforts to promote social capital as a mechanism for reducing poverty and promoting economic development are underway in the UK and Australia. ii Along with prevention, cessation and elimination of secondhand smoke Section: 9.0.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 3 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: < 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. Section: 9.0.2.2 Date of last update: 20 November 2012 Tobacco in Australia: 4 Facts and Issues 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 olderi 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 includedii. 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 Victoriaiii for adults 16 years and over in 197427 and 197728 and then every three years until 1998.iv 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. i Since 2004, young people aged 12 and 13 years have been included in the National Drug Strategy Household Surveys. However analysis of the data is mostly based on those aged 14 years and older to allow for comparisons with earlier survey findings. ii In Australia these would represent a very small percentage, probably less than half of one per cent, of the total population (see Section 9.6 for estimates of numbers of homeless, prisoners and institutionalised persons). iii Now known as ‘Cancer Council Victoria’. iv The surveys conducted for Cancer Council Victoria and for the Australian Bureau of Statistics were face-to-face interviews. The National Drug Strategy Household Survey uses a combination of face-to-face surveys, drop and collect surveys and telephone surveys. Section: 9.0.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 5 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.i 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 Study45, 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 i Data on smoking are also available from another Australian Bureau of Statistics survey undertaken in 1977. Section: 9.0.3 Date of last update: 20 November 2012 Tobacco in Australia: 6 Facts and Issues References 1. Graham H, and Kelly MP. Health inequalities: concepts, frameworks and policy. Briefing paper. London: Health Development Agency, 2004. Available from:http://www.nice.org.uk/ niceMedia/pdf/health_inequalities_policy_graham.pdf 2. Australian Bureau of Statistics. 2039.0 Information paper: an introduction to Socio-Economic Indexes for Areas (SIEFA) 2006. Canberra: ABS, 2008. Available from: http://abs.gov.au/ AUSSTATS/[email protected]/DetailsPage/2039.02006 3. Adhikari P. 1351.0.55.015 Research paper: socio-economic indexes for areas: introduction, use and future directions. Canberra: ABS, 2006. Available from: http://www.abs.gov.au/ AUSSTATS/[email protected]/Lookup/1351.0.55.015Main+Features1Sep%202006 4. The World Bank Group. Social capital implementation framework. Washington DC: World Bank, 2008. May 2011 [viewed April 30, 2012]. Available from: http://go.worldbank.org/ BSM1HUUIT0 5. Berkman L, and Glass T. Social integration, social networks, social supports and health. In Berkman L, andKawachi I, eds. Social epidemiology. New York: Oxford University Press, 2000: 137–73. Available from: http://www.amazon.com/Social-Epidemiology-Lisa-F-Berkman/dp/0195083318 6. Department of Health. Healthy lives, healthy people: our strategy for public health in England. London: Department of Health, 2010. Available from: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/DH_121941 7. Department of Health. Equity and excellence: liberating the NHS. London: Department of Health, 2010. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_117353 8. Health and Social Care Act. 2012 (UK). Available from: http://www.legislation.gov.uk/ukpga/2012/7/notes/division/2 9. National Health Service Act. 2006 (UK). Available from: http://www.legislation.gov.uk/ukpga/2006/41/contents 10. Louis G. Surveillance recommendations for developing effective tobacco prevention and control interventions for low-SES populations. Health Promotion Practice. 2008;10(2):276–83. Available from: http://hpp.sagepub.com/content/10/2/276.long 11. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2007. Available from:http://www.cdc.gov/ tobacco/tobacco_control_programs/ntcp/index.htm 12. Ministerial Council on Drug Strategy. Australian National Tobacco Strategy 2004-2009. Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/ internet/main/publishing.nsf/Content/tobacco-strat 13. Gillard J, and Wong P. An Australian social inclusion agenda: Election 2007. Canberra: Australian Labor Party, 2007. Available from: http://www.alp.org.au/download/now/071122_ social_inclusion.pdf 14. National Health Priority Action Council. National Chronic Diseases Strategy. Canberra: Australian Government Department of Health and Ageing, 2006. Available from: http://www.health. gov.au/internet/main/publishing.nsf/content/pq-ncds-strat 15. Boyd M. Reducing health inequalities. Melbourne, Australia: Victorian Health Promotion Foundation, 2007. Available from: http://www.vichealth.vic.gov.au/inequalities 16. VicHealth. VicHealth position statement on health inequalities. Melbourne, Australia: Victorian Health Promotion Foundation, 2005. Available from: http://www.vichealth.vic.gov.au/ Publications/Health-Inequalities.aspx 17. Australian Government. Taking preventative action: Government’s response to the Australia: the healthiest country by 2020. Canberra: Department of Health and Ageing, 2010. Available from: http://yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/report-preventativehealthcare 18. Fagan P, Moolchan E, Lawrence D, Fernander A, and Ponder P. Identifying health disparities across the tobacco continuum. Addiction. 2007;102(suppl. 2):5–29. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/17850611 19. Kawachi I, Subramanian SV, and Almeida-Filho N. A glossary for health inequalities. Journal of Epidemiology and Community Health. 2002;56(9):647–52. Available from: http://jech. bmj.com/cgi/content/full/56/9/647 20. Graham H. Why social disparities matter for tobacco-control policy. American Journal of Preventive Medicine. 2009;37(suppl. 2):S183–4. Available from: http://www.ajpm-online.net/ article/PIIS0749379709002888/fulltext 21. Graham H. Tackling inequalities in health in England: remedying health disadvantages, narrowing health gaps or reducing health gradients. Journal of Social Policy. 2004;33:115–31. Available from: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=198421 22. Mackenbach J, and Kunst A. Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Social Science & Medicine. 1997;44(6):757–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9080560 23. Adhikari P, and Summerill A. 1998 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 6, AIHW cat. no. PHE 27. Canberra: Australian Institute of Health and Welfare, 1999. Available from: http://www.aihw.gov.au/publications/index.cfm/title/6243 24. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: survey report. Drug statistics series no 25, AIHW cat. no. PHE 145. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712 25. Australian Institute of Health and Welfare. 2004 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 16, AIHW cat. no. PHE 66. Canberra: AIHW, 2005. Available from: http://www.aihw.gov.au/publications/phe/ndshsdf04/ndshsdf04.pdf 26. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 22, AIHW cat. no. PHE 107. Canberra: AIHW, 2008. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10674 27. Gray N, and Hill D. Patterns of tobacco smoking in Australia. Medical Journal of Australia. 1975;2(22):819–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1207580 28. Gray N, and Hill D. Patterns of tobacco smoking in Australia II. Medical Journal of Australia. 1977;2(10):327–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/927253 Section: 9.0.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 7 29. Hill D, and Gray N. Patterns of tobacco smoking in Australia. Medical Journal of Australia. 1982;1(1):23–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7062879 30. Hill D, and Gray N. Australian patterns of smoking and related health beliefs in 1983. Community Health Studies. 1984;8(3):307–16. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/6518750 31. Hill D. Australian patterns of tobacco smoking in 1986. Medical Journal of Australia. 1988;149(1):6–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3386578 32. Hill D, and White V. Australian adult smoking prevalence in 1992. Australian Journal of Public Health. 1995;19(3):305–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7626682 33. Hill DJ, White VM, and Gray NJ. Measures of tobacco smoking in Australia 1974-1986 by means of a standard method. Medical Journal of Australia. 1988;149(1):10–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3386561 34. Hill DJ, White VM, and Scollo MM. Smoking behaviours of Australian adults in 1995: trends and concerns. Medical Journal of Australia. 1998;168(5):209–13. Available from: http://www. mja.com.au/public/issues/mar2/hill/hill.html 35. White V, Hill D, Siahpush M, and Bobevski I. How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001. Tobacco Control. 2003;12(suppl. 2):ii67-74. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/12/suppl_2/ii67 36. Australian Bureau of Statistics. 4364.0 National Health Survey 1989-90: summary of results. Canberra: ABS, 1992. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/ DetailsPage/4364.01995 37. 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Available from: http://www.abs.gov.au/ausstats/abs@. nsf/mf/4363.0.55.001 42. Hayes L, Durkin S, and Wakefield M. Smoking prevalence and consumption in Victoria: key findings from the 1998–2010 population surveys. CBRC Research Paper Series, no. 42. Melbourne, Australia: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2011. Available from: http://www.cancervic.org.au/about-our-research/centre_behavioural_ research_cancer/cbrc_research_paper_series 43. Tobacco Control Research and Evaluation. Key smoking statistics for South Australia, 2008. Adelaide: Cancer Council South Australia, , 2008. Available from: http://www.cancersa.org.au/ cms_resources/Key_%20Smoking_Statistic_for_SA_2008_web_layout.pdf 44. The Social Research Centre. National Tobacco Survey: smoking prevalence and consumption 1997-2005. Sydney: SRC for the Research and Marketing Group, Business Group, Department of Health and Ageing, 2006. Available from: http://www.quitnow.gov.au/internet/quitnow/publishing.nsf/Content/national-tobacco-campaign-lp 45. Fong GT, Cummings KM, Shopland DR, and ITC Collaboration. Building the evidence base for effective tobacco control policies: the International Tobacco Control Policy Evaluation Project (the ITC Project). Tobacco Control. 2006;15(suppl 3):iii1–2. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii1 46. Thompson ME, Fong GT, Hammond D, Boudreau C, Driezen P, Hyland A, et al. Methods of the International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15(suppl 3):iii12-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16754941 47. Melbourne Institute of Applied Economic and Social Research. The Household, Income and Labour Dynamics in Australia (HILDA) Survey. Melbourne: University of Melbourne, 2011. 1 Feb 2012 [viewed 30 April 2012]. Available from: http://melbourneinstitute.com/hilda/ 48. Australian Bureau of Statistics. 6503.0 Household Expenditure Survey and Survey of Income and Housing: summary of results, 2009-10. Canberra: ABS, 2011. Available from: http:// www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/6530.02009-10?OpenDocument 49. White VM, Hayman J, and Hill DJ. Can population-based tobacco-control policies change smoking behaviors of adolescents from all socio-economic groups? Findings from Australia: 1987–2005 Cancer Causes & Control. 2008;19(6):631–40. Available from: http://www.springerlink.com/content/x1h33x711616h254/ 50. White V, and Smith G. Chapter 3. Tobacco use among Australian secondary students. Australian secondary school students’ use of tobacco, alcohol, and over-the-counter and illicit substances in 2008. Canberra: Drug Strategy Branch Australian Government Department of Health and Ageing, 2009. Available from: http://www.nationaldrugstrategy.gov.au/internet/ drugstrategy/Publishing.nsf/content/school08 Section: 9.0.3 Date of last update: 20 November 2012 Tobacco in Australia: 8 Facts and Issues 9.1 Socio-economic position and disparities in tobacco exposure and use Socio-economic disparities are evident in exposure to tobacco and in tobacco use, from before birth, during childhood, during adolescence and early adulthood and right through adult life. 9.1.1 Disparities in smoking during pregnancy Data from the 2010 National Drug Strategy Household Survey indicate that female smokers in the most disadvantaged socio-economic group consumed almost twice the number of cigarettes per week as women who were least disadvantaged (an average 113.5 compared with 66.1 cigarettes per week).1 Data from state perinatal statistics units indicated that women from Aboriginal or Torres Strait Islander backgrounds were more than three times more likely to smoke during pregnancy than non-Indigenous women (49.6% compared with 13.1%).i Likelihood of smoking during pregnancy decreased with maternal age. Thirty- seven per cent of teenagers who become pregnant report that they continued to smoke.2 Other research has shown that disadvantage across a woman’s life course increases the risk of being a smoker at pregnancy.3 Women without a partner, the less educated,4,5 those of lower socio-economic status,4,6 those living in a deprived neighbourhood7 and women with a psychiatric disorder8 are more likely to smoke during pregnancy. 9.1.2 Disparities in exposure of children to secondhand smoke Children from disadvantaged families are far more Table 9.1.1 likely to be exposed to secondhand smoke at home. Percentage of children exposed to smoking in the home, by quintile of Lower household income, lower parental (or head disadvantage, Australia, 2010 of house) education level and living with multiple adult smokers are predictive of children’s exposure 9,10 to smoking in the home. % % of these % of children % of these Quintile of households who only exposed to Data analysed from the 2010 National Drug who smoke disadvantage* with at least smoke some indoor indoors Strategy Household Survey indicate that while the one smoker outdoors smoking majority of households with dependent children Lowest 51.1 77.40 22.60 11.5 where at least one person smokes only allow Second 41.4 87.10 12.90 5.3 smoking outdoors, this is significantly less likely to Third 34.6 84.90 15.10 5.2 be the case for children in the most disadvantaged Fourth 30.7 91 9.00 2.8 areas (77% of smoking households with bans Highest 19.5 90.40 9.60 1.9 on smoking indoors in the most disadvantaged Likelihood of compared with 90% in the least disadvantaged lowest compared 2.62 0.86 2.35 6.17 areas). Given the higher rates of smoking among with highest those in the disadvantaged groups, this means that children from the most disadvantaged areas of Australia are more than six times more likely Source: Gartner and Hall 201211 to be exposed to smoking in their own homes as * Based on socio-economic indexes for areas, Australian Bureau of Statistics i Different states have used different criteria for assessing smoking status, and routinely collect data at different times in the pregnancy (prior to first antenatal visit, at first antenatal visit, at birth). Provisional data were supplied for Victoria for this report and limited to Perinatal National Minimum Data Set data items. The numbers of mothers and babies in Victoria in Australia may change when the final data are used. Section: 9.1.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 9 children from the most advantaged areas. More than 1 in every 10 of these highly disadvantaged children live in a household where at least one adult at least occasionally smokes indoors. Although children of many low socio-economic status (SES) smokers are exposed daily to tobacco smoke in the home, legislative developments, such as bans in Australian states and territories on smoking in cars carrying children (see Chapter 15, Section 15.7.2.3), help reduce the number of areas where children may be exposed to secondhand smoke. Widespread smokefree legislation means that children of non-smoking parents might not be exposed to environmental tobacco smoke at all, for months at a time. Research from overseas reports the same associations between deprivation and the likelihood of secondhand smoke exposure in children, with maternal and paternal smoking habits, household poverty and lower parental educational levels being common predictors of exposure.9, 10, 12, 13 9.1.3 Disparities in smoking behaviours among young people In 2008 in Australia, younger students living in disadvantaged areas were more likely to experiment with smoking than students living in more advantaged areas. Figure 9.1.1 shows that in 2008, younger students living in the most advantaged areas of Australia were about 15% less likely to report having smoked at some time in the last month than students residing in the least advantaged areas.14 Among older students in 2008, smoking was more common among students from more advantaged areas, with students from most advantaged SES areas about 25% more likely to smoke than those from the most disadvantaged areas. Among younger students (aged 12–15 years) in 2008, while there was little difference in the prevalence of current smoking across the different SES groups, smoking was slightly more common among the least advantaged groups (Figure 9.1.2). 15 10 15 9 13 12 8 11 8 8 8 10 12 to 15 6 16 & 17 % % 6 4 5 5 5 5 2 0 0 Most disadvantaged Most advantaged Most disadvantaged Most advantaged Figure 9.1.1 Figure 9.1.2 Proportion of monthly smokers among secondary-school students Proportion of weekly smokers among secondary school students aged aged 12–15 years by relative socio-economic disadvantage, Australia, 12–15 and 16–17 years by relative socio-economic disadvantage, 2008 Australia, 2008 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council, April 2012, Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council, April 2012, by V White, Centre for Behavioural Research in Cancer, Cancer Council Victoria by V White, Centre for Behavioural Research in Cancer, Cancer Council Victoria Section: 9.1.3 Date of last update: 20 November 2012 Tobacco in Australia: 10 Facts and Issues 9.1.4 Disparities in smoking prevalence among adults Consistent with findings from the US,15–17 UK,18,19 Canada,20,21 New Table 9.1.2 Zealand22,23 and other developed countries,24–31 data on current smoking Prevalence of daily smoking, Australians 15 years from recent Australian Bureau of Statistics National Health Surveys,32-35 and over by socio-economic and labour force status, recent National Drug Strategy Household Surveys,1,36,37 and surveys 2007–08 assessing the impact of the National Tobacco Campaign38 and state Quit campaigns,39 all show a clear social gradient in smoking behaviour among adults, with rates of current smoking significantly higher and the 2007–08 proportion of people who have never smoked significantly lower in lower Persons (%) socio-economic groups. Total population, 15 years+ 18.3 Labour force status Table 9.1.2 sets out Australian data from the 2007–08 National Health Employed 19.3 Survey published by the Australian Bureau of Statistics. Unemployed 32.0 The 2010 National Drug Strategy Household Survey tells a similar story. Index of disadvantage Table 9.1.3 sets out data on smoking status among those of varying 5th quintile (most advantaged) 11.0 employment status, those with and without post-school qualifications, 1st quintile (most disadvantaged) 27.6 and those living in areas marked by varying levels of income, educational attainment and unemployment. (Note that the figures in Table 9.1.3 cover the population from 14 years of age and so they vary somewhat Source: Australian Bureau of Statistics 200935 (p32) from those in Chapter One, Section 1.7, which computed adult smoking prevalence just for those respondents aged 18 years and over.) Figure 9.1.3 plots data on smoking status by the level of social disadvantage of the area that people live in. Table 9.1.3 The proportion of people who classify themselves as Socio-economic characteristics by smoking status, persons 14 years and ex-smokers is almost identical among people living in older, Australia, 2010 areas of varying degrees of social disadvantage. Never Ex- Smokers‡ Characteristic smoked* smokers† (%) (%) (%) All persons (aged 14+) 57.8 24.1 18.1 Labour force status Currently employed 54.9 25.5 19.6 70 1st quintile (most disadvantaged) Student 85.0 4.8 10.3 63 2nd quintile 60 Unemployed 55.7 16.7 27.6 60 56 57 3rd quintile 53 Engaged in home duties 54.2 25.7 20.1 50 4th quintile 5th quintile (least disadvantaged) Retired or on a pension 53.7 35.0 11.3 40 Volunteer/charity work 60.1 20.4 19.5 % Unable to work 42.4 22.2 35.4 30 26 24 24 25 Other 53.4 22.8 23.8 23 24 21 20 18 16 Education 13 10 Without post-school qualifications 59.8 20.7 19.5 With post-school qualifications 56.2 26.8 17.0 0 Never smoker Ex-smoker Current smoker Main language spoken at home English 55.5 26.1 18.4 Other 80.4 8.0 11.6 Figure 9.1.3 Smoking status by relative social disadvantage, persons 14 years and Source: Australian Institute of Health and Welfare 2011 1 Table 3.4 (p27) older, Australia, 2010: never smokers, ex-smokers and current smokers * Never smoked more than 100 cigarettes or the equivalent tobacco in their life Source: Australian Institute of Health and Welfare 20111 Table 3.4 (p28) † Smoked at least 100 cigarettes or the equivalent tobacco in their life, and no longer smoke ‡ Smoked daily, weekly or less than weekly Section: 9.1.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 11 9.1.5 Disparities in reported cigarette consumption In addition to being more likely to have ever smoked Table 9.1.4 and to be current smokers, those in disadvantaged Mean number of cigarettes smoked per day, (self-reported) current smokers groups also generally report smoking a greater aged 14 years and older, by social characteristics, by sex, Australia, 2010 number of cigarettes each day.32,40 Characteristic Males Females Persons 9.1.6 Mean number of cigarettes smoked/day All persons (aged 14+) 15.5 13.8 14.7 Disparities in duration of Education Without post-school qualifications 17.2 14.9 16.0 smoking With post-school qualifications 14.2 12.6 13.6 Among people who have quit smoking, those with Employment Currently employed 14.6 12.6 13.8 lower levels of occupation, income and education are Student 7.2 8.0 7.6 likely to have smoked for longer periods of time prior Unemployed 20.0 14.9 17.9 to quitting. Table 9.1.5 sets out the mean number Engaged in home duties 18.7 14.3 14.5 of years prior to quitting for people who reported Retired or on a pension 17.3 17.4 17.3 being ex-smokers in the 2001 National Drug Strategy Volunteer/charity work 26.2 18.1 22.6 41,42 Household Survey. Unable to work 24.0 17.9 20.8 Results of multivariate analysis showed that smoking Other duration from onset to cessation was 14% longer Socio-economic status for persons with blue collar rather than professional 1st quintile (most disadvantaged) 18.9 16.2 17.6 occupations. Respondents who earned $299 or less 2nd quintile 16.1 15.3 15.8 per week smoked 38% longer than did those earning 3rd quintile 15.6 12.6 14.2 $800 or more. Individuals with nine or fewer years of 4th quintile 13.0 13.1 13.1 5th quintile (most advantaged) 10.6 9.4 10.0 education smoked 13% longer than those with 12 or Main language spoken at home more. English 16.1 13.8 15.0 Table 9.1.5 Note, however that Other 9.3 8.9 9.2 trends in smoking Indigenous status Mean duration of smoking prior to cessation are not Aboriginal and/or Torres Strait quitting, Australia, 2001 25.0 17.6 21.0 uniformly more Islander favourable in Other Australian 15.1 13.5 14.4 higher SES groups Median duration for all age and of smoking (years) Source: Adapted from Australian Institute of Health and Welfare 20111 Table 3.9. (p36) gender groups. Occupation Blue collar 30 A cross-sectional White collar 22 study of young, middle-aged and older women in Australia for instance found Professional 19 that for women aged 70–75 years, those with the highest educational attainment Family income ($ pw) were more likely to have ever smoked than those with the lowest level of Less than 300 35 attainment. This was in contrast to findings for the other two cohorts, where 300–799 24 this association was reversed, with a stronger association between low levels 800 and more 16 of education and ever smoking among those aged 18–23 years (younger) than Education (years) those aged 45–50 years (mid-age). Similarly, for older women, those in the most 9 or less 33 skilled occupational classes were most likely to have ever smoked, with opposite 10–11 25 findings for mid-age women.43 The differences in patterns of uptake between 12 or more 18 cohorts may be explained by trends towards greater social freedom for women since the late 1960s. In the US, marked differences in the duration of smoking were found between Source: Siahpush et al 200542 racial groups as well as socio-economic groups. Most minority racial groups were Section: 9.1.6 Date of last update: 20 November 2012 Tobacco in Australia: 12 Facts and Issues likely to smoke for longer periods and individuals living in poverty smoked on a daily basis for 18 years longer than those with a family income about three times above the poverty line.44 Cohort patterns in smoking uptake and quitting are discussed further in Section 9.7. 9.1.7 Disparities in exposure to secondhand smoke Because more of them smoke, people in more disadvantaged groups are also more likely to be exposed to secondhand smoke both where they work and where they live. 9.1.7.1 Disparities in workplace exposure 25 Total ban Since the mid-1980s in Australia, when smoking was 21 No restrictions 20 banned in the federal public service offices and then, 18 increasingly in big and then smaller companies (see Chapter 15, Section 15.4), people in higher status occupations 15 % 12 have been more likely to work in places with total bans on 10 9 8 smoking. While most workplaces since the late 1980s have 7 restricted smoking to at least some degree, as shown in 5 Figure 9.1.4, as recently as the late 1990s, blue collar workers were three times more likely to work in environments with 0 Blue collar White collar Professional no restrictions on smoking. With legislation mandating smokefree policies in hospitality venues and in enclosed workplaces in all Australian Figure 9.1.4 jurisdictions (with some exemptions, such as high-roller Proportion of workers reporting a total ban and proportion reporting rooms), disparities in workplace exposure to environmental no restrictions on smoking in their workplace, Australia 1998: blue tobacco smoke are no doubt much less pronounced in more collar compared with white collar and professional workers recent times. Data collected from annual population surveys Source: Adhikari and Summerill 199845 in Victoria showed for instance, that the proportion of indoor workers reporting total smoking restrictions at their usual area of work increased significantly between 1998 and 2007 (from 91% to 95%). The data indicated there was a relatively uniform increase in workplace smoking bans across all socio-economic groups for this period. However some disparity between smokefree workplaces does still exist, with 91% of warehouse, workshop and factory workers reporting a smokefree workplace compared with the average of 95% of all indoor workplaces.46 9.1.7.2 Disparities in domestic exposure In the 1998 National Drug Strategy Household Survey, almost 50% of respondents with a university degree stated that they did not allow smoking inside their home. For those with no tertiary qualifications the figure was only 34%.47 Among Australian smokers in 2010–11, those on lower incomes were much more likely to allow smoking anywhere in their house (Figure 9.1.5). In 2008–09, 82% of university-educated smokers reported never smoking when non-smokers were present in their cars—only slightly more than smokers who had not completed high-school education (Figure 9.1.6). Section: 9.1.7.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 13 80 Less than $10,000 Did not nish high school 74 90 $10,000 to $29,000 Completed high-school 82 70 80 77 79 $30,000 to $44,999 65 Trade or technical quali cation 76 60 $45,000 to $99,999 70 Some University 54 Over $100,000 50 60 % 50 % 40 39 34 31 32 40 30 20 30 20 21 14 20 19 17 16 10 7 10 4 3 5 2 0 0 Smoking allowed anywhere Smoking never allowed anywhere Smoke as normally do Something in between Never smoke at all Figure 9.1.5 Figure 9.1.6 Current smokers’ rules about smoking in the home, by annual Current smokers’ smoking behaviour around non-smokers in cars, by household income, Australia 2010–11 educational status, Australia 2008–09 Source: Data file of responses to eighth wave of the International Tobacco Control Four-country 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 Survey provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, 2012 T Partos and R Borland , 2012 Note: Figures are percentages Note: Figures are percentages 9.1.7.3 Exposure in institutional settings People spending time in institutions such as correctional facilities, psychiatric hospitals and drug treatment centres are among the most disadvantaged groups in Australia. 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Available from: http://www.sciencedirect.com/science/journal/01638343 Section: 9.1.7.3 Date of last update: 20 November 2012 Tobacco in Australia: 16 Facts and Issues 9.2 Socio-economic disparities in tobacco exposure and use: are the gaps widening? While it is clear that smoking rates are higher among disadvantaged than among advantaged groups in Australia, much less clear is whether disparities have been widening over time. The answer depends most crucially on the period of time over which one analyses the data. In addition, the extent of differential changes in rates in different socio-economic (SES) groups also seems to vary depending on the indicator of SES status, the data set and the jurisdiction being examined. An assessment of the impact of the Californian Tobacco Control Program in reducing prevalence in higher- educated and less-educated population groups provides insight into the complexity in measuring the effect of strategies to reduce relative disparity between groups. Zhu and colleagues explain that population-wide tobacco- control strategies that are known to be effective in reducing smoking prevalence may not necessarily work to reduce disparity between population sub-groups. They note the challenge in tobacco control lies in eliciting an increase in the rate of change in less-advantaged groups, so as to reduce disparity between less-advantaged and more-advantaged groups.1 The factors that serve to negate the effects of population-wide strategies among the most disadvantaged are addressed in Sections 9.4 and 9.5 and considerations around the impact of population-wide strategies on the disadvantaged appear in Section 9.8. Insufficient data are available to examine trends over time in smoking during pregnancy, however the following sections present data on trends since 1980 in disparities in smoking by adults, together with limited data about emerging disparities among children. 9.2.1 Changes in the prevalence of smoking among adults in various socio-economic groups Trends over time in smoking prevalence among different social groups can be difficult to interpret because of changing social and economic conditions. With increasing school retention in Australia and introduction of financial assistance for tertiary students in the mid-1970s,i a much more diverse group of people in the 1990s are achieving higher levels of formal educational qualification compared with that group of people who undertook tertiary education in the late 1960s and early 1970s. In a period of low unemployment and a buoyant job market, the unemployed in the mid-2000s on the other hand may be less socially diverse than groups who were unemployed during times of low job vacancies in the 1980s and 1990s. Towards the end of the decade, the unemployment rate had steadily declined to 4.2% (in 2008); however as a result of the global financial crisis in the latter part of 2008, unemployment in Australia rose to 5.6% in 2009.3 Rates of school retention have increased since 1998 among young people.4 Also, increasingly over time people born prior to World War II (who are much less likely to have completed school)5 are being lost from the total population. Thus, part of the explanation for any flattening of smoking rates in people who have not completed Year 12 could be that this is becoming a group characterised by more social and economic disadvantage than was the case in previous cohorts. In 2009, the proportion of Australians aged 25–64 years with a vocational or higher education qualification was 63% (compared with 46% in 1997). The increase is mostly attributable to more Australians achieving a higher education qualification, such as a bachelor degree or more. The achievement of higher education relates to the increase in participation in schooling over time. The proportion of young people continuing education through to Year 12 has increased from 45% in 1984 to 76% in 2009.2 i Participation rates in Year 12, for instance, increased from 45% in 1984 to 76% in 2009.2 Section: 9.2.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 17 Inconsistencies in methods of collecting data and in SES categories over time make long-term analysis difficult. To get a reliable picture of trends in SES-related disparities in smoking, it is therefore useful to look at relative changes across several socio-economic indicators and using several different data sets. 9.2.1.1 Table 9.2.1 Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment Changes in prevalence among those with Education Reduction 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 Drop level (%) varying levels of Year 9 or less 35.5 35.8 31.9 30.4 29.8 30 27.9 23.9 22.8 24.3 24.1 12.7 36 Year 10 & 11 37.9 37.6 34.9 31.9 29.5 30.5 32.7 29.9 30.0 28.5 26.7 7.9 21 formal education Year12/post- 37.6 34.1 32.9 28.4 29.1 23.5 28.2 22.0 22.0 20.6 19.1 15.6 41 secondary Table 9.2.1 sets out the Trade 34.9 34.4 29.6 29.4 29.2 25.6 28.2 27.2 28.3 26.1 25.6 6.6 19 prevalence of current smoking University 28.8 28.6 22.9 21.3 19.6 20 20.1 14.8 13.3 12 11.6 15.5 54 among people with various levels of education between i 1980 and 2010. Adjusting Sources: Hill and Gray 1982,6 1984,7 Hill 1988,8 Hill, White and Gray 1991,9 Hill and White 1995,10 Hill, White and Scollo 1998,11 White et al 2003;12 for age and gender, analysis Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 201116 of these data shows that the Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 6–12 13–16 prevalence of smoking found 1980–98, and from the National Drug Strategy Household Survey 2001–10 . See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as ‘current smokers’ (no in every educational level in frequency specified). Since 2001, the figures include those reporting that they smoke ‘daily’ or ‘at least weekly’. 2010 was significantly lower All data weighted to 2001 census population data and may vary slightly from data presented in the previous edition than that found in 1980. * Includes persons smoking any combination of cigarettes, pipes or cigars As is evident from Table 9.2.1, the decline in prevalence 40 of smoking for the total 30-year period covered by these 35 surveys was most substantial among those who had 30 Years 10 and 11 graduated from university, but was also substantial among 25 those who had finished secondary school and those who left Trade quali cations % 20 school before Year 10. Year 12 or post-secondary 15 Figure 9.2.1 plots this data, omitting figures for those who 10 University graduate left school before Year 10. (Given the historically lower or attended some uni minimum leaving age for school, and the historically lower 5 rates of participation by women in tertiary education, this 0 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 group would comprise mainly older people with varying levels of income and living in varying circumstances. Older populations also exclude people who have died prematurely Figure 9.2.1 due to smoking.) Prevalence of regular smokers in Australia aged 18+, 1980–2010, by educational attainment Figure 9.2.1 would seem to indicate that smoking fell Sources: Hill and Gray 1982,6 1984,7 Hill 1988,8 Hill, White and Gray 1991,9 Hill and White roughly equally among people of various educational levels 1995,10 Hill, White and Scollo 1998,11 White et al 2003;12 Australian Institute of Health between 1980 and 1992. Declines have flattened since the and Welfare 2002,13 2005,14 2008,15 201116 mid-1980s in less educationally qualified groups, but note Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research the apparent fall in all groups between 1998 and 2001.ii in Cancer, Anti-Cancer Council of Victoria, from 1980–98,6-12 and from the National Drug Strategy Household Survey 2001–1013-16. See footnote ii in Chapter 1, Section Since 2004, declines have continued across all groups, with 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to greater reductions in prevalence in the less-qualified and 2001, figures represent those describing themselves as ‘current smokers’ (no frequency less-educated groups compared with university qualified. specified). Since 2001, the figures include those reporting that they smoke ‘daily’ or ‘at The pattern of these changes is discussed in more detail in least weekly’. Section 9.8. All data weighted to 2001 census population data and may vary slightly from data presented in the previous edition * Includes persons smoking any combination of cigarettes, pipes or cigars i For data for males and females to 2007, refer to Chapter 1, Table 1.7.1. ii As discussed in Section 9.8, this was the period in Australia when the National Tobacco Campaign was most active and reforms of taxes on cigarettes resulted in very large price rises in budget brands. Section: 9.2.1.1 Date of last update: 20 November 2012 Tobacco in Australia: 18 Facts and Issues 9.2.1.2 Table 9.2.2 Changes in Prevalence of regular smokers in Australia aged 18+, 1980–2010: by occupational status prevalence in blue Reduction 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 drop versus white collar (%) Upper white collar 32.5 28.1 24.0 22.7 19.7 19.0 18.1 16.0 14.0 12.9 13.4 18.5 57 groups Lower white collar 37.2 37.8 30.6 28.1 25.8 23.4 23.7 24.8 22.8 22.6 19.6 14.4 39 Upper blue collar 47.9 41.3 36.8 34.0 32.7 32.3 30.5 29.8 28.3 28.3 24.8 19.6 41 A quick reading of all Lower blue collar 51.5 46.3 44.2 40.4 36.7 41.1 39.8 35.4 34.8 34.5 29.7 16.7 32 the studies published on Not in paid work 27.0 30.5 27.3 25.0 24.6 24.1 25.3 20.6 20.8 17.6 18.9 6.20 23 smoking prevalence in Australia over the past 6 7 8 9 10 11 12 30 years would seem Sources: Hill and Gray 1982, 1984, Hill 1988, Hill, White and Gray 1991, Hill and White 1995, Hill, White and Scollo 1998, White et al 2003; Australian Institute of Health and Welfare 2002,13 2005,14 2008,15 2011;16 Adhikari P and Summerill A 199918 to indicate that the gap Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, from 1980–986, in smoking prevalence 7,8,9-11,12 and from the National Drug Strategy Household Survey 1998–201013-16, 18. See footnote ii in Chapter 1, Section 1.2 for explanatory notes between blue and white regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as ‘current smokers’ (no frequency collar groups has widened specified). Since 2001 the figures include only reporting that they smoke daily or at least weekly. considerably.17 However Classifications changed in 2010 such that some occupations that would have been classed as upper blue in 2007 may be classified as lower blue in 2010. as discussed in Chapter Tradespersons are classified as upper blue in 2010 but would have been classified as lower white in previous years. All data weighted to 2001 census population data and may vary slightly from data presented in previous edition One, Section 1.7, surveys * Includes persons smoking any combination of cigarettes, pipes or cigars have varied greatly in the age ranges reported and the ways that occupational status has been defined. Table 9.2.2 sets out smoking prevalence between 1980 55 and 2010 for all occupational groups using data collected 50 in surveys conducted by the Anti-Cancer Council of 45 40 Victoria (now Cancer Council Victoria) until 1998, and Lower blue 35 then the National Drug Strategy Household Survey, both 30 Upper blue % re-analysed to include just people 18 years and over. 25 The decline in prevalence of smoking has been substantial 20 Lower white 15 across groups. The declines were proportionately greater 10 Upper white among white collar workers than blue collar workers; 5 overall, prevalence of smoking among upper white collar 0 workers more than halved over this study period (57%) 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 while among lower blue collar workers, prevalence dropped by just over 30%. But is that the full story? Figure 9.2.2 Combining upper and lower blue collar groups and upper Prevalence of regular smokers in Australia aged 18+, 1980–2010, by and lower white collar groups obscures some interesting occupational status differences between the four groups at various points of Source: Sources: Hill and Gray 1982,6 1984,7 Hill 1988,8 Hill, White and Gray 1991,9 Hill and White 10 11 13 time. 1995, Hill, White and Scollo 1998, Australian Institute of Health and Welfare 2002, 2005,14 2008,15 2011;16 Adhikari P and Summerill A 199918 Figure 9.2.2 sets out the data from Table 9.2.2, omitting the Notes: Based on analysis of data from surveys conducted by the Centre for Behavioural Research in 6, 7,8,9-11 figures for those not in paid work.i Cancer, Anti-Cancer Council of Victoria, from 1980–98 and from the National Drug Strategy Household Survey 1998– 201013-16, 18. See footnote ii in Chapter 1, Section 1.2 for explanatory notes regarding methodology used in attaining this data set. Prior to 2001, figures represent those describing themselves as ‘current smokers’ (no frequency specified). Since 2001 the figures include only reporting that they smoke daily i While the ‘not in paid work’ category is likely to include a proportion of socio-economically or at least weekly. disadvantaged people, who as a demographic group demonstrate a higher prevalence Classifications changed in 2010 such that some occupations that would have been classed of smoking, this category also includes retired people (older people being less likely to as upper blue in 2007 may be classified as lower blue in 2010. Tradespersons are classified smoke than younger people—Table 1.4), those engaged in domestic duties (more likely as upper blue in 2010 but would have been classified as lower white in previous years. to be female than male, and hence to have a lower smoking prevalence—Table 1.2), and Includes persons smoking any combination of cigarettes, pipes or cigars students in post-secondary education (who are less likely to be smokers than those with a All data weighted to 2001 census population data and may vary slightly from data lower level of education level—Table 1.6). presented in previous edition Section: 9.2.1.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 19 Examining Figure 9.2.2, it is clear that smoking rates over the 1980s and early 1990s declined roughly equally in absolute terms among various occupational groups. Disparities appear to have widened briefly in the mid-1990s before the downward trend in smoking resumed in all four occupational groups. It is also evident that one could get a very different picture of the relative declines among occupational groups in recent years depending on the period examined. Comparing 2010 with 1992 (showed by the dotted line in Figure 9.2.2), one would conclude that white collar groups did much better than blue. However comparing 2010 with 1995 (showed by the solid line), the decline would appear to be roughly equal, with a slight flattening in declines among upper white collar groups between 2007 and 2010. The implications of this pattern of decline are also discussed further in Section 9.8. Figures 9.2.1 and 9.2.2 demonstrate the importance of avoiding simplistic point-in-time comparisons. Detailed statistical analysis is required to determine relative patterns of change over particular time periods. Table 9.2.3 35 Percentage smokers in Australia and measures of absolute change and relative change, 2001–10, persons aged 18 years and over, by socio- 30 economic index for area SEIFA 1 25 % SEIFA 2 20 Absolute Relative 2001 2004 2007 2010 SEIFA 3 change change SEIFA 4 15 Socio-economic % SEIFA 5 index for area (SEIFA) 10 SEIFA 1 (most 2001 2004 2007 2010 25.5 30.5 29.2 27.2 2 7 disadvantaged) SEIFA 2 27.9 25.9 23.5 22.2 –6 –20 Figure 9.2.3 SEIFA 3 26.4 23.5 21.7 18.7 –8 –29 Percentage smokers in Australia, persons 18 years and over, 2001–10, SEIFA 4 24.5 19.3 18.4 16.9 –8 –31 SEIFA 5 (most by socio-economic index for area 19.4 16.6 15.4 13.4 –6 –31 advantaged) Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, Absolute difference from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, 6 14 14 14 Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, between Q1 and Q5 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished Relative difference 24 46 47 51 data, 2012. between Q1 and Q5 Note: The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012. Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years. The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. 9.2.1.3 Changes in smoking prevalence by area-level measures of SES Similar to the picture with occupational status, it is easy to see a significantly greater decrease in smoking prevalence among groups living in more advantaged compared with those living in less advantaged areas. This section provides analyses of smoking prevalence in males and females aged 18 years and older, by socio-economic index for areas (SEIFA). Between 2004 and 2010 smoking prevalence among adults declined significantly across all SEIFAs. The greatest declines between 2007 and 2010 were seen in SEIFAs 3 and 5. Section: 9.2.1.3 Date of last update: 20 November 2012 Tobacco in Australia: 20 Facts and Issues Among males, significant declines in smoking prevalence were seen across all SEIFA groups with the exception of SEIFA 1, the most disadvantaged, where there was a significant increase in smoking prevalence (see Table 9.2.4 and Figure 9.2.4). Table 9.2.4 Percentage smokers in Australia and measures of absolute change and 35 relative change, males aged 18 years and over, 2001–10, by socio- 30 economic index for area SEIFA 1 25 SEIFA 2 % Relative SEIFA 3 Absolute 20 2001 2004 2007 2010 change SEIFA 4 change 2001–10 15 Socio-economic SEIFA 5 % index for area (SEIFA) 10 SEIFA 1 (most 2001 2004 2007 2010 27.3 31.4 30.7 29.0 2 6 disadvantaged) SEIFA 2 29.9 27.5 26.1 23.7 –6 –21 SEIFA 3 28.3 26.5 22.2 20.1 –8 –29 Figure 9.2.4 SEIFA 4 27.2 21.3 21.3 19.8 –7 –27 Percentage smokers in Australia, males 18 years and over, 2001–10, SEIFA 5 (most by socio-economic index for area 22.7 18.6 16.7 14.3 –8 –37 advantaged) Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Absolute difference 5 13 14 15 Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, between Q1 and Q5 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished Relative difference data, 2012. 17 41 46 51 between Q1 and Q5 Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years. The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/ Disadvantage is based on a continuum of advantage to disadvantage. Source and notes: see Figure 9.2.4 Table 9.2.5 Percentage smokers in Australia and measures of absolute change and relative change, females 18 years and over, 2001–10, by socio-economic 35 index for area 30 Absolute Relative 25 SEIFA 1 2001 2004 2007 2010 change change % SEIFA 2 Socio-economic 20 % index for area (SEIFA) SEIFA 3 SEIFA 1 (most 15 24.0 29.6 27.7 25.4 1 6 SEIFA 4 disadvantaged) SEIFA 5 SEIFA 2 25.8 24.5 21.1 20.8 –5 –19 10 2001 2004 2007 2010 SEIFA 3 24.5 20.4 21.2 17.3 –7 –29 SEIFA 4 22.0 17.3 15.5 14.0 –8 –36 SEIFA 5 (most 16.1 14.5 14.1 12.4 –4 –23 Figure 9.2.5 advantaged) Percentage smokers in Australia, females 18 years and over, 2001–10, Absolute difference 8 15 14 13 by socio-economic index for area between Q1 and Q5 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, Relative difference from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, 33 51 49 51 between Q1 and Q5 Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012. Notes: After standardising for age, prevalence in SEIFA 1 was lower in 2001 than SEIFA 2 and 3. Source and notes: see Figure 9.2.5 In original (unstandardised) data, SEIFA 1 had the highest prevalence in all years. Section: 9.2.1.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 21 Among females, smoking prevalence declined significantly in all SEIFAs through the nine-year period 2001–10 (see Table 9.2.5 and Figure 9.2.5). The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. However, once again, such simplistic point-in-time comparisons obscure important differences between males and females in various categories of disadvantage. They also say little about the reliability of prevalence estimates given the quite small sample sizes that result from dividing the population into five groups. But has the differential between SES groups increased over time? Interestingly, the gradient of decline in female smoking prevalence is less pronounced across SEIFA groups. Smoking prevalence in the most advantaged group (SEIFA 5) declined less so than in SEIFA 3 and 4. In 2010, there was double the proportion of female smokers in SEIFA 1 than in SEIFA 5. However it reflects a fairly stable differential in smoking prevalence between SEIFAs 1 and 5 since 2004. Similarly in males, the proportion of smokers in the least advantaged (SEIFA 1) was double that of those in the most advantaged group (SEIFA 5). The data show a slight pattern of widening disparity in prevalence between these groups over 2004–10. 9.2.2 Differential uptake or differential cessation? In the population overall, smoking has reduced due to a combination of fewer people taking up smoking, more people quitting, and more smokers than non-smokers dying prematurely. Table 9.2.6 and Figure 9.2.6 show the proportion of person who identified as never smokers, across SEIFA quintiles using data from the ABS National Drug Strategy Household Surveys between 2001 and 2010. The proportion of never smokers in the most disadvantaged group was 45% in 2001 and almost 50% in 2010. In comparison, almost 53% of those in the most advantaged group were never smokers in 2001 and this increased to Table 9.2.6 70 Percentage never smokers in Australia, persons 18 years and over, 2001–10, by socio-economic index for area SEIFA 1 60 SEIFA 2 SEIFA 3 SEIFA 4 Absolute Relative % 50 2001 2004 2007 2010 SEIFA 5 change change Socio-economic % 40 index for area (SEIFA) SEIFA 1(most 45.4 43.4 45.7 49.6 4 9 disadvantaged) 30 SEIFA 2 43.9 46.4 50.1 53.1 9 21 2001 2004 2007 2010 SEIFA 3 46.5 48.8 54.0 54.5 8 17 SEIFA 4 47.5 53.6 54.4 57.2 10 20 Figure 9.2.6 SEIFA 5 (most Percentage never smokers in Australia, persons 18 years and over, 52.6 54.3 56.9 60.5 8 15 advantaged) 2001–10, by socio-economic index for area Absolute difference Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, –7 –11 –11 –11 between Q1 and Q5 from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Relative difference Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, –16 –25 –25 –22 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished between Q1 and Q5 data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Source and notes: see Figure 9.2.6 Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Section: 9.2.2 Date of last update: 20 November 2012 Tobacco in Australia: 22 Facts and Issues 60.5% by 2010. The increase in never smokers in the most disadvantaged group was more modest compared to those of SEIFA 5 (most advantaged), as well as SEIFAs 2, 3 and 4. Although the proportion of the population who are never smokers has increased across all SEIFA groups, the gap between highest and lowest SEIFA appeared to widen between 2001 and 2007, with little evidence of any substantial narrowing between 2007 and 2010. Table 9.2.7 and Figure 9.2.7 show the proportion of males who identified as never smokers, across SEIFA quintiles using data from the Australian Institute of Health and Welfare (AIHW) National Drug Strategy Household Surveys between 2001 and 2010. Table 9.2.7 70 Percentage never smokers in Australia, males 18 years and over, 2001–10, by socio-economic index for area 60 SEIFA 1 SEIFA 2 Absolute Relative % 50 SEIFA 3 2001 2004 2007 2010 change change SEIFA 4 SEIFA 5 Socio-economic index % for area (SEIFA) 40 SEIFA 1 (most 39.2 37.1 39.9 44.5 5 14 disadvantaged) 30 SEIFA 2 37.4 41.7 44.0 48.5 11 30 2001 2004 2007 2010 SEIFA 3 40.2 43.7 50.4 49.4 9 23 SEIFA 4 40.4 48.4 47.4 52.5 12 30 Figure 9.2.7 SEIFA 5 (most 46.0 50.3 54.4 58.0 12 26 Percentage never smokers in Australia, males 18 years and over, advantaged) 2001–10, by socio-economic index for area Absolute difference –7 –13 –15 –14 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, between Q1 and Q5 from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, Relative difference –17 –36 –36 –30 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished between Q1 and Q5 data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Source and notes: see Figure 9.2.7 The data indicate that the proportion of males identifying as never smokers has increased between 2001 and 2010, across all SEIFA groups. The proportion of never smokers in SEIFA 5 in 2001 was 46%. This increased by 12% (in absolute terms) to 58% in 2010. In comparison, 39% of males in SEIFA 1 reported being never smokers in 2001; this increased by 5% (in absolute terms) to 44.5% in 2010. However the proportions of never smokers are still substantially higher in the most advantaged group compared to the most disadvantaged group. The disparity between never smokers in the lowest and highest socio-economic group appears to have widened between 2001 and 2007, beyond this time it seems the disparity between the groups has narrowed little. Table 9.2.8 and Figure 9.2.8 show the proportion of females who identified as never smokers, across SEIFA quintiles using data from the ABS National Drug Strategy Household Surveys between 2001 and 2010. Proportions of never smoking in females have increased since 2001 across all SEIFA groups, with the most marked increase for women in SEIFA 4. The proportions of never smokers are still substantially higher in the most advantaged group compared to the least advantaged group. The disparity between the groups—although not having widened greatly since 2001—has, nevertheless, failed to narrow substantially during this period. Table 9.2.9 and Figure 9.2.9 detail quitting patterns among adults across SEIFA quintiles. Again data from the AIHW’s National Drug Strategy Household Surveys 2001–10 have been used in this analysis. The proportion of adults quitting smoking since 2001 has increased, most notably among SEIFAs 3, 4 and 5. The relative change in quitting has been modest among adults in SEIFA 2. In the most disadvantaged group, quitting Section: 9.2.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 23 Table 9.2.8 70 Percentage never smokers in Australia, females 18 years and over, 2001–10, by socio-economic index for area SEIFA 1 SEIFA 2 60 SEIFA 3 SEIFA 4 SEIFA 5 Absolute Relative % 50 2001 2004 2007 2010 change change Socio-economic index 40 % for area (SEIFA) SEIFA 1 51.3 48.9 51.2 54.4 3 6 30 2001 2004 2007 2010 SEIFA 2 50.2 51.0 55.5 57.3 7 14 SEIFA 3 52.5 53.7 57.7 59.0 6 12 SEIFA 4 53.9 58.5 61.3 61.9 8 15 Figure 9.2.8 SEIFA 5 58.7 58.0 59.3 62.8 4 7 Percentage never smokers in Australia, females 18 years and over, Absolute difference 2001–10, by socio-economic index for area –7 –9 –8 –8 between Q1 and Q5 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, Relative difference from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, –14 –19 –16 –15 Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, between Q1 and Q5 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes Source and notes: see Figure 9.2.8 for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Table 9.2.9 70 Percentage of ever smokers who have quit in Australia and measures of SEIFA 1 absolute change and relative change, persons 18 years and over, 2001–10, SEIFA 2 60 by socio-economic index for area SEIFA 3 SEIFA 4 % 50 Absolute Relative SEIFA 5 2001 2004 2007 2010 change change 40 Socio-economic index % for area (SEIFA) SEIFA 1 (most 30 53 46 46 46 –7 –13 2001 2004 2007 2010 disadvantaged) SEIFA 2 50 52 53 53 3 5 SEIFA 3 51 54 53 59 8 16 Figure 9.2.9 SEIFA 4 53 58 60 61 7 13 Percentage of ever smokers who have quit in Australia and measures SEIFA 5 (most 59 64 64 66 7 12 of absolute change and relative change, persons 18 years and over, advantaged) 2001–10, by socio-economic index for area Absolute difference –6 –18 –18 –20 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, between Q1 and Q5 from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, Relative difference –11 –38 –39 –44 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished between Q1 and Q5 data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Source and notes: see Figure 9.2.9 behaviour decreased between 2001 and 2004 and then remained stable, neither increasing nor decreasing over this time. Note the relative difference in quitting proportions between SEIFA 1 and SEIFA 5, with an indication of a widening disparity over the survey years. Section: 9.2.2 Date of last update: 20 November 2012 Tobacco in Australia: 24 Facts and Issues Table 9.2.10 Percentage of ever smokers who have quit in Australia and measures of 70 absolute change and relative change, males 18 years and over, 2001–10, SEIFA 1 by socio-economic index for area 60 SEIFA 3 SEIFA 4 SEIFA 2 % 50 Absolute Relative SEIFA 5 2001 2004 2007 2010 change change Socio-economic index 40 % for area (SEIFA) SEIFA 1 (most 55.2 50.0 48.8 47.7 –7 –13 30 disadvantaged) 2001 2004 2007 2010 SEIFA 2 52.2 52.9 53.4 54.0 2 3 SEIFA 3 52.7 52.9 55.2 60.3 8 14 Figure 9.2.10 SEIFA 4 54.4 58.7 59.5 58.3 4 7 Percentage of ever smokers who have quit in Australia and measures SEIFA 5 (most 58.0 62.5 63.4 66.0 8 14 advantaged) of absolute change and relative change, males 18 years and over, 2001–10, by socio-economic index for area Absolute difference –3 –13 –15 –18 between Q1 and Q5 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, Relative difference Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, –5 –25 –30 –38 between Q1 and Q5 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Source and notes: see Figure 9.2.10 Advantage/Disadvantage is based on a continuum of advantage to disadvantage. Table 9.2.10 and Figure 9.2.10 show quitting patterns among males and females by socio-economic index for area. Among Australian males, quitting behaviour shows no clear gradient across socio-economic groups between 2001 and 2010. An increase in the proportion of quitters is evident across all SEIFAs, with the exception of the most disadvantaged, SEIFA 1. The data on quitting habits in males indicate a growing differential between the most advantaged and least advantaged socio-economic groups. Table 9.2.11 and Figure 9.2.11 show quitting patterns among females by socio-economic index for area. In females, the proportion quitting among the most advantaged group is less than among their male counterparts. Again, there is not a strong gradient in quitting behaviour across all SEIFAs, although every SEIFA except SEIFA 1 had an increase in quitting behaviour between 2001 and 2010. The social gradient in quitting proportions between the most advantaged and least advantaged females is less pronounced than in males; however the gap between these groups has not lessened over this period. Interestingly, in data collected on Victorian adult smoking prevalence over a 25-year period, researchers reported that population-wide strategies such as tax increases, mass media campaigns and smokefree policies may have been just as influential on those in low socio-economic groups as among those in high socio-economic groups. They found that in the period 1984–2008, adults in the lowest socio-economic groups experienced greater relative increases in quitting proportions (75%) than those in high socio-economic groups (50%) and mid-socio-economic groups (37%). Those in the lower-to-mid socio-economic groups also had the greatest rates of decline in ever smoking over the 25-year period in comparison to the most advantaged groups.19 In 2010, 81% of regular smokers in Victoria reported making at least one quit attempt during their lifetime. This represented a relative increase of 7% from 1998, where the proportion of regular smokers who had made at least one quit attempt was 76%. Significant linear increases in the proportions of regular smokers who had ever made a quit attempt were seen in the low and mid socio-economic groups, but significant increases were not seen in the most advantaged socio-economic group. There was also a significant increase in the proportion of regular smokers making multiple quit attempts (defined as three or more attempts), from 37% in 1998 to 49% in 2010. This appears related to downward trends in the proportion of regular smokers who had made one or two attempts, and those who had never attempted to quit smoking. Between the years 2004 and 2010, a significant increase in the Section: 9.2.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 25 Table 9.2.11 70 Percentage of ever smokers who have quit in Australia and measures of SEIFA 1 absolute change and relative change, females 18 years and over, 2001–10, SEIFA 4 60 by socio-economic index for area SEIFA 3 % 50 SEIFA 2 Absolute Relative 2001 2004 2007 2010 change change SEIFA 5 Socio-economic index 40 % for area (SEIFA) SEIFA 1 (most 50.6 42.0 43.2 44.3 –6 –12 30 disadvantaged) 2001 2004 2007 2010 SEIFA 2 48.2 49.9 52.6 51.4 3 7 SEIFA 3 48.4 55.9 49.9 57.9 9 20 SEIFA 4 52.3 58.2 59.9 63.3 11 21 Figure 9.2.11 SEIFA 5 (most Percentage of ever smokers who have quit in Australia and measures 60.9 65.6 65.4 66.7 6 9 advantaged) of absolute change and relative change, females 18 years and over, Absolute difference 2001–10, by socio-economic index for area –10 –24 –22 –22 between Q1 and Q5 Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, Relative difference from Centre for Behavioural Research in Cancer. CBRC, Cancer Council Victoria. Melbourne, –20 –56 –51 –50 between Q1 and Q5 Australia. Analysis of National Drug Strategy Household Survey data 2001, 2004, 2007, 2010, age standardised data, by SEIFA Index of Advantage/Disadvantage.Unpublished data, 2012. Note: The data are grouped in quintiles calculated using one of the socio-economic indexes Source and notes: see Figure 9.2.11 for areas (SEIFA) developed by the Australian Bureau of Statistics. The ABS’s Index of Advantage/Disadvantage is based on a continuum of advantage to disadvantage. proportion of successful quit attempts (in the five years preceding the 2010 survey) was reported for Victorians in the most disadvantaged socio-economic group.20 Vangeli and colleagues conducted a systematic review of literature to distinguish predictors of quit attempts and quitting success among Table 9.2.12 adult general population samples. The studies Self-reported cigarettes smoked (number per week) by Australian adult smokers examined were methodologically diverse, but (factory-made cigarettes only), 1980–2010, by occupational class suggested past quit attempts and motivational factors were highly predictive of quit attempts, and cigarette dependency was consistently Lower blue Upper blue Lower white Upper white Not in Year predictive of a successful quit attempt. Socio- collar collar collar collar labour force economic status appeared to be predictive of 1980 144.9 141.4 129.5 131.6 131.6 success (note, however, it was examined in 1983 168.7 147.7 140.0 163.8 149.1 only two of the studies). Other demographic 1986 161.0 149.8 138.6 157.5 147.0 factors—gender, age, marital status and 1989 167.3 163.8 151.2 165.9 162.4 educational level—were not consistently 1992 148.4 156.1 122.5 140.0 151.2 connected with quit attempts or quitting 1995 137.2 140.7 118.3 133.0 137.2 success across the countries examined.21 1998 134.4 144.2 114.1 138.6 136.5 2001* 140.6 123.7 109.1 105.7 134.4 2004 134.9 119.7 103.8 104.8 133.1 9.2.3 2007 132.8 121.4 105.4 101.1 133.5 2010 148.0 115.2 104.8 97.6 135.5 % change Changes in consumption +2 19 19 26 +3 1980–2010 % change of cigarettes +5 7 4 8 +1 2001–10 Table 9.2.12 illustrates consumption levels among smokers of varying occupational classes. Declines in consumption were Source: Australian Institute of Health and Welfare 2001,13 2004,14 2007,15 201016 considerable in upper white collar, lower * Consumption assessed using a different method in 2001 to that used in later years. Section: 9.2.3 Date of last update: 20 November 2012 Tobacco in Australia: 26 Facts and Issues white collar and upper blue collar groups, yet consumption among the lower blue collar group actually increased across this period. 9.2.4 Changes in the prevalence of 20 smoking among students in 18 16 schools in areas of varying levels 14 12 of disadvantage % 10 8 Lowest Higher levels of uptake among disadvantaged groups 6 Highest Second appear to have been even more significant than lower levels 4 Third of cessation as a driver of socio-economic disparities in 2 i 0 smoking in Australia. To assess the likelihood of increasing 1987 1990 1993 1996 1999 2002 2005 2008 disparity in the future, researchers could more carefully analyse rates of never smoking and cessation among different SES groups in cohorts of adults born since 1970. Figure 9.2.12 Reported current smoking (smoking in the last week), secondary Data on smoking rates among secondary school students students in Australia aged 16 and 17 years, 1987–2008, ranked by of different socio-economic backgrounds provide some quartiles of advantage by the area in which the student lived indication of what future smoking disparities by SES Sources: White, Hayman and Hill 200823, Table 2; and data file provided to Merryn Pearce of may be. the Tobacco Control Unit, Cancer Council, April 2012, by V White, Centre for Behavioural Research in Cancer, Cancer Council Victoria Information on socio-economic backgrounds of students is not collected in surveys of youth smoking in Australia. Figures 9.2.12 and 9.2.13 show smoking rates among young people aged 16 and 17 years and 12–15 years between 35 1987 and 2008 according to the level of disadvantage of the neighbourhood in which they lived. 30 25 Declines in student smoking rates have been substantial Second Lowest across all quartiles since the late nineties and early 2000s, 20 % Highest with the exception of students living in the lowest socio- 15 economic area, where declines there have been more Third modest. 10 5 Interestingly, a sharp decline in smoking was evident across the period 1987–2005 among students living in the most 0 1987 1990 1993 1996 1999 2002 2005 2008 advantaged areas; however declines in this group have appeared to flatten in the three years to 2008. By 2008, smoking rates in students living in the third, second and Figure 9.2.13 lowest areas of advantage were lower than the smoking rates Reported current smoking (smoking in the last week), secondary of students in the most advantaged areas. students in Australia aged 12–15 years, 1987–2008, ranked by quartiles of advantage by the area in which the student lived Following a sharp reversal of the socio-economic gradient Sources: White, Hayman and Hill 200823, Table 2; and data file provided to Merryn Pearce of among young people aged 12–15 years between 1990 and the Tobacco Control Unit, Cancer Council, April 2012, by V White, Centre for Behavioural 1996, between 1996 and 2008 smoking declined roughly Research in Cancer, Cancer Council Victoria equally among students at all levels of disadvantage, however again a flattening in smoking prevalence is apparent between 2005 and 2008 for those living in the highest quartile, so that there is only small variation in smoking rates between the groups at 2008. i An analysis of generational trends in the UK similarly found that while rates of uptake were higher among manual workers than non-manual workers, manual workers born before 1950 were equally as likely to give up smoking as non-manual workers born before 1950.22 Section: 9.2.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 27 9.2.5 Changes in childhood exposure to smoking in the household In 2010, 77% of the most Table 9.2.13 disadvantage households Percentage of households who reported smoking only outdoors in the last 12 months, Australia, 2001, 2004, 2007 with dependent children and 2010, socio-economic index for areas: households with dependent children where at least one person was a smoker smoked only outdoors. Year % The proportion of change between 2001 2004 2007 2010 outdoor-only smoking 2001 and 2010 in this group rose by Quintile % (95% CI) % (95% CI) % (95% CI) % (95% CI) % 95% CI 50% from 2001. In Lowest 51.5 (46.1–56.9) 56.6 (52.2–61.0) 72.3 (67.1–77.4) 77.4 (72.9–81.8) 50.2 (32.3–68.1) 2010, 90.4% of the most Second 50 (45.7–54.3) 66.8 (62.7–70.9) 78.3 (73.1–83.5) 87.1 (83.2–90.9) 74.1 (57.2–91.1) advantaged households Third 57.6 (52.1–63.0) 76.2 (72.5–80.0) 80.9 (76.0–85.9) 84.9 (80.6–89.1) 47.4 (31.6–63.1) Fourth 58.8 (52.5–65.0) 72.3 (68.1–76.4) 82.3 (77.3–87.2) 91 (87.6–94.4) 54.9 (37.5–72.3) containing dependent Highest 67.2 (61.3–73.2) 80.8 (76.0–85.5) 81.3 (74.7–87.9) 90.4 (85.8–95.0) 34.4 (20.7–48.2) children smoked only Gap lowest 15.7* (7.7–23.7) 24.2 (17.7–30.6) 9.1* (0.7–17.4) 13.0* (6.6–19.5) outdoors (see Table to highest 9.2.13). Gartner and Hall 24 examined trends in Source: Gartner and Hall 2012 the social gradient of * Result should be interpreted with caution because Relative Standard Error lies between 25% and 50%. children’s exposure to secondhand smoke in Australian households between 2001 and 2010. They found that exposure of children to tobacco smoke in the home decreased substantially over the decade, except in the case of the most disadvantaged households, where about half of households with a child still contained at least one smoker. On this measure, their research showed the disparity between household secondhand smoke exposure in children had increased between the least advantaged and most advantaged households.24 Sims and colleagues collected data on secondhand smoke exposure in children (measured by mean cotinine levels) in England between 1996 and 2006. Children from more deprived households were most exposed, however across the 11-year research period secondhand smoke exposure in children declined substantially, with a 59% decline in geometric mean cotinine levels over this time. The most marked declines were observed immediately before the introduction of smokefree legislation in England and among children who were most exposed at the outset.25 9.2.6 International comparisons Observations of smoking and its connection with socio-economic disadvantage and widening disparities between the most and least advantaged social classes are not confined to the Australian population. Survey data in the UK show more rapid declines in smoking among non-manual workers compared with manual workers since the 1970s, contributing to a widening of proportions of smokers between these groups. It reported smoking as nearly twice as common in routine and manual households as in managerial and professional households (28% compared to 15%). The authors noted the ‘striking’ differences between various social classes. Smoking prevalence was particularly high among economically inactive people aged 16–59 years, whose last job was a routine or manual one; 50% of these people were smokers.26 Observations on adult smoking and emerging disparities between social classes have been made in research out of New Zealand,27 Italy,28 the US and Canada29–31 and France.32 Section: 9.2.6 Date of last update: 20 November 2012 Tobacco in Australia: 28 Facts and Issues References 1. Zhu S, Hebert K, Wong S, Cummins S, and Gamst A. Disparity in smoking prevalence by education: can we reduce it? Global health promotion. 2010;17(suppl. 1):29–39. Available from: http://ped.sagepub.com/content/17/1_suppl/29.full.pdf+html 2. Australian Bureau Statistics. 6278.0 Education and Training Experience. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/mf/6278.0 3. 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Available from: http://tobaccocontrol.bmj.com/cgi/content/full/12/suppl_2/ii67 13. Australian Institute of Health and Welfare. 2001 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 11, AIHW cat. no. PHE 41. Canberra: AIHW, 2002. Available from: http://www.aihw.gov.au/publications/index.cfm/title/8227 14. Australian Institute of Health and Welfare. 2004 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 16, AIHW cat. no. PHE 66. Canberra: AIHW, 2005. Available from: http://www.aihw.gov.au/publications/phe/ndshsdf04/ndshsdf04.pdf 15. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 22, AIHW cat. no. PHE 107. Canberra: AIHW, 2008. Available from: http://www.aihw.gov.au/publications/index.cfm/title/10674 16. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: survey report. Drug statistics series no 25, AIHW cat. no. PHE 145. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712 17. Smith DR. Tobacco smoking by occupation in Australia and the United States: a review of national surveys conducted between 1970 and 2005. Industrial Health 2008;46:77-89. Available from: http://www.jstage.jst.go.jp/article/indhealth/46/1/46_77/_article 18. Adhikari P, and Summerill A. 1998 National Drug Strategy Household Survey: detailed findings. Drug statistics series no 6, AIHW cat. no. PHE 27. Canberra: Australian Institute of Health and Welfare, 1999. Available from: http://www.aihw.gov.au/publications/index.cfm/title/6243 19. Germain D, Durkin S, Scollo M, and Wakefield M. The long-term decline of adult tobacco use in Victoria: changes in smoking initiation and quitting over a quarter of a century of tobacco control. Australian and New Zealand Journal of Public Health. 2012;36(1):17-23. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00805.x/full 20. Centre for Behavioural Research in Cancer. Current and former smokers’ quitting activity and intentions: findings from the 1998-2010 Victorian Smoking and Health Surveys, unpublished data. Melbourne, Australia: CBRC, 2011. Available from: 21. Vangeli E, Stapleton J, Smit ES, Borland R, and West R. Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review. Addiction. 2011;106(12):2110-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21752135 22. Davy M. Socio-economic inequalities in smoking: an examination of generational trends in Great Britain. Health Statistics Quarterly. 2007(34):26–34. Available from: http://www. statistics.gov.uk/articles/hsq/HSQ34_Smoking.pdf 23. White VM, Hayman J, and Hill DJ. Can population-based tobacco-control policies change smoking behaviors of adolescents from all socio-economic groups? Findings from Australia: 1987–2005 Cancer Causes & Control. 2008;19(6):631–40. Available from: http://www.springerlink.com/content/x1h33x711616h254/ 24. Gartner CE, and Hall WD. Is the socioeconomic gap in childhood exposure to secondhand smoke widening or narrowing? Tobacco Control. 2012; [Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22467710 25. Sims M, Tomkins S, Judge K, Taylor G, Jarvis MJ, and Gilmore A. Trends in and predictors of second-hand smoke exposure indexed by cotinine in children in England from 1996 to 2006. Addiction. 2010;105(3):543–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20402999 26. Robinson S, and Harris H. Smoking and drinking among adults, 2009. A report on the 2009 General Lifestyle Survey. London: Office of National Statistics, 2011. Available from:http:// www.ons.gov.uk/ons/rel/ghs/general-lifestyle-survey/2009-report/index.html 27. Barnett R, Pearce J, and Moon G. Community inequality and smoking cessation in New Zealand, 1981–2006 Social Science & Medicine. 2009;68(5):876–84. Available from: http://www. ncbi.nlm.nih.gov/pubmed/19136183 28. Federico B, Costa G, Ricciardi W, and Kunst AE. Educational inequalities in smoking cessation trends in Italy, 1982-2002. Tobacco Control. 2009;18(5):393-8. Available from: http:// tobaccocontrol.bmj.com/cgi/content/abstract/18/5/393 29. Chilcoat HD. An overview of the emergence of disparities in smoking prevalence, cessation, and adverse consequences among women. Drug and Alcohol Dependence. 2009;suppl. 1:S17-23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19632070 Section: 9.2.6 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 29 30. Reid J, Hammond D, and Driezen P. Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use? Canadian Journal of Public Health. 2010;101(1):73–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20364543 31. Smith P, Frank J, and Mustard C. Trends in educational inequalities in smoking and physical activity in Canada: 1974 to 2005. Journal of Epidemiology and Community Health. 2009;63(4):317–23. Available from: http://jech.bmj.com/content/63/4/317.long 32. Peretti-Watel P, Constance J, Seror V, and Beck F. Cigarettes and social differentiation in France: is tobacco use increasingly concentrated among the poor? Addiction. 2009;104(10):1718– 28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19681803 Section: 9.2.6 Date of last update: 20 November 2012 Tobacco in Australia: 30 Facts and Issues 9.3 Contribution of smoking to health inequality As is the case elsewhere in the world, ill-health and rates of premature death in Australia show a clear gradient across socio-economic status (SES) groups.1–3 People who are poorer or disadvantaged in other ways generally suffer more illness and reduced quality of life and die earlier than people who are better off. The social gradient holds regardless of how socio-economic disadvantage is measured.1 People who are disadvantaged are more likely to live with multiple risks to their health. Lower socio-economic status is associated with higher rates of obesity, lack of adequate physical activity and diabetes—especially so among Indigenous communities.1,2,4 However, with or without such additional risk factors, current smokers are much less likely than non-smokers to be in good health and the incidence of numerous diseases is significantly higher among smokers and recent ex- smokers than among long-time ex-smokers and never smokers.5,6 Social differentials in smoking during pregnancy, smoking prevalence, cigarette consumption, duration of smoking and exposure to environmental tobacco smoke must contribute substantially to socio-economic differentials in health status and mortality. This section outlines data on relative rates of poor health, disease, mortality and life expectancy across SES groups, and also presents estimates of the contribution of smoking to these health disparities. 9.3.1 Socio-economic position, reported health status and smoking People who live in disadvantaged areas are much less likely to assess their own health as excellent or good.1, 2 Data from Australian national surveys commonly report higher rates of arthritis, chronic respiratory disease, cardiovascular disease and depression in least advantaged groups in comparison to more advantaged groups in the population.2,7–9 The rates of profound disability and type 2 diabetes in low socio-economic areas are double that of those in the highest socio-economic areas.2 In 2010, only 41% of smokers participating in the National Drug Strategy Household Survey reported their overall health as ‘very good’ or ‘excellent’, compared to 50% of ex-smokers and almost 60% of non-smokers. Ex-smokers were more likely to report diagnoses or treatment for heart disease and cancer than smokers and non-smokers. Smokers were more likely to report asthma, and twice as likely as non-smokers to have been diagnosed with, or treated for, mental illness.10 9.3.2 Socio-economic position and illnesses known to be caused by smoking Hospitalisations for cardiovascular disease show a clear socio-economic gradient. In 2003–04 rates of hospitalisations for males in the most disadvantaged socio-economic group were 1.3 times those of males of least socio-economic disadvantage. The hospitalisation rate for the most disadvantaged females was higher again, with rates 1.4 times that of females in the least disadvantaged socio-economic group. A socio-economic gradient is evident for other chronic diseases for which smoking is a risk factor, with hospitalisations for coronary heart disease and stroke among males and females increasing as socio-economic status decreases.11 Section: 9.3.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 31 The Australian Institute of Health and Welfare has estimatedi that lung cancer was the fourth leading cause of disease among males and the seventh leading cause of disease among females in 2011. Lung cancer incidence is disproportionately high in those of lower socio-economic status in Australia, with increasing incidence of lung cancer associated with decreasing socio-economic status, across the five years 2003–2007. In the year 2008–09, the rate of hospitalisations for lung cancer was higher for those living in the lowest socio-economic areas of Australia. Those living in the lowest socio-economic areas were hospitalised for lung cancer at 1.5 times the rate of those living in areas of highest socio-economic advantage.12 Chronic kidney disease has increasingly been shown to be connected with smoking and cardiovascular disease.13, 14 It is more common in low socio-economic groups and particularly so among Indigenous Australians.2, 14 Between 2000–01 and 2007–08, hospitalisations for chronic kidney disease were highest for Australians living in the most disadvantaged areas. Hospitalisations for kidney dialysis among the lowest socio-economic group were 1.6 times the rate of those in the most advantaged group. After removing the rates for regular dialysis from all chronic kidney disease-related hospitalisations, the rates of hospitalisations among the lowest socio-economic group remained almost twice that of the most advantaged group.15 The worsening of asthma symptoms is known to be associated with active smoking and/or exposure to secondhand smoke. Smoking and asthma are both more common in those living in low socio-economic areas. The Australian Centre for Asthma Monitoring (a collaborating unit of the Australian Institute of Health and Welfare) reported that in 2007–08, not only was asthma much more common among those living in the most deprived socio- economic areas in Australia, but that rates of smoking among asthmatics in low socio-economic areas were far higher than for asthmatic smokers living in areas of higher socio-economic status (37.8% and 12.9% respectively). The disparity between the lowest and highest socio-economic group in asthma prevalence was found to have widened between survey years 2004–05 and 2007–08.16 9.3.3 Socio-economic disparities in death rates from diseases known to be caused by smoking Australians from lower socio-economic groups have a greater proportion of chronic disease mortality burden than those living in more advantaged areas.17 This sub-section presents information on socio-economic disparities in mortality rates from diseases associated with smoking, however it is important to note the influence and interplay of other health risk factors and social and economic deprivation across a life-course, in the contribution to disease and premature mortality among the disadvantaged. Section 9.3.5 provides a detailed discussion on quantifying the contribution of smoking to socio-economic differentials in heath status; associations between childhood circumstances and health outcomes, smoking and intergenerational poverty are discussed further in Section 9.5. The potential years of life lost (PYLL)ii due to cancer deaths in 2007 was greater among Australians living in the most disadvantaged areas (55%) compared with those living in the least disadvantaged areas (42%). A gradient across socio-economic groups was evident for cardiovascular disease, chronic respiratory disease, digestive diseases and diabetes, whereby the proportion of PYLL due to premature mortality from these diseases were represented more highly in those living in lower socio-economic areas.17 According to data compiled by the Public Health Information Development Unit in South Australia, a strong economic gradient was evident for premature mortality associated with lung cancer, with more avoidable lung cancer deaths in the most disadvantaged areas (25.9 per 100 000) compared with those in the least disadvantaged areas (15.2 per 100 000) between 2003 and 2007.18 Similar trends of a disproportionate level of mortality burden being borne among those of less socio-economic advantage have been observed in international studies. i Estimate projected from a 2003 baseline, derived from AIHW Burden of Disease database, see table 7.1. (p.70)12 ii Potential years of life lost (PYLL): ‘an indicator of premature death. PYLL are determined by age at death and takes in to account only deaths that occur before a particular age’.17 Section: 9.3.3 Date of last update: 20 November 2012 Tobacco in Australia: 32 Facts and Issues A 24-year study of British men and women examined the relationship between socio-economic status and mortality, and the influence smoking, alcohol consumption, diet and physical activity have on mortality. In terms of all-cause mortality, those of lowest socio-economic position had 1.6 times the risk of death in comparison with those of higher socio-economic position. There was also a graded association for cardiovascular disease mortality and socio-economic position. Health risk behaviours, including smoking, were connected with mortality.19 Studies of cancer mortality in the US show disparities related to socio-economic position and also to ethnicity.20,21 9.3.4 Socio-economic disparities in health-adjusted life expectancy As part of research on preventable causes of disease conducted for the Australian Government, researchers at the University of Queensland examined differentials in the burden of disease across socio-economic groups.6 At birth, those in the lowest socio- Table 9.3.1 economic quintile could expect Life expectancy, Australia, 2003, by socio-economic quintile to die at least three years earlier than those in the highest economic quintile (79.6 compared with 82.7 Health-adjusted Health-adjusted Life expectancy Life expectancy years). Adjusting for ill-health, those life expectancy at life expectancy at at birth lost due at birth (years) in the lowest quintile could expect birth (years) age 60 (years) to disability (%) to live four years less than those in Socioeconomic quintile the highest quintile. By the age of Low 79.6 (79.4–79.7) 71.2 17.9 10.6 60, those in the lowest quintile could Moderately low 80.0 (79.9–80.2) 72.0 18.2 10.1 expect 15% fewer years of health- Average 80.2 (80.0–80.3) 72.2 18.4 9.9 adjusted life than those in the highest Moderately high 81.2 (81.1–81.4) 73.6 19.3 9.4 quintile (Table 9.3.1). High 82.7 (82.5–82.8) 75.5 20.6 8.7 Difference between –3.9 –6.0 –15.1 17.9 Researchers estimated that, for lowest and highest (%) the year 2003, a total of 2 632 800 disability-adjusted life years (DALYS) were lost in Australia. DALYs were Source: Begg et al 20076 calculated for each of the five socio- Table 9.3.2 economic quintiles (Table 9.3.2). Disability-adjusted life years lost, Australia, 2003, by socio-economic quintile, Australia, 2003 After adjusting for age, loss rates were 31.7% higher in the lowest SES quintile than in the highest.6 Rates of burden were higher for most causes, but particularly for mental disorders and cardiovascular disease. DALYs (‘000) % of total Per head of population, rates of burden were 26.5% higher in remote Socioeconomic quintile areas than in major cities.3, 6 Low 562.5 21.4 Life expectancy among Indigenous Australians is discussed in Chapter 8. Moderately low 564.2 21.4 Average 523.6 19.9 In the US, researchers examined the effects of a number of health risk Moderately high 507.7 19.3 factors, including smoking, on life expectancy and disparities in life High 474.8 18.0 expectancy in eight sub-groups of the population. Individually, smoking Total 2 632.8 100.0 and high blood pressure had the most profound effect on life expectancy disparities. They found that variation of life expectancies in the eight sub- groups would decline by 18% in men and 21% in women if the health Source: Begg et al 20076 risks (smoking, blood pressure, elevated blood glucose, and adiposity or DALY = disability-adjusted life year obesity) had been reduced to optimal levels.22 The Whitehall study followed more than 18 000 English males over a period of 38 years to examine life expectancy in relation to cardiovascular risk factors, which were recorded at middle age. The study reported that the presence of all three risk factors (smoking, high blood pressure and high cholesterol) at baseline (middle-age) predicted a three-fold rate of vascular mortality and about a 10-year reduced life expectancy from age 50 years, when compared with men who had none of the risk factors present at the commencement of the study.23 Section: 9.3.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 33 9.3.5 Quantifying the contribution of smoking to socio-economic differentials in health status Estimates of the contribution of smoking to social inequality vary, likely due to differences in study methodology and datasets. Estimates may also be affected by declines in smoking prevalence in developed countries, changing social demographics, latency of disease and death associated with smoking, and the emergence of other risk factors and their contribution to disease and mortality. This section presents research across time and using differing methods to quantify the contribution of smoking to health inequalities. Section 9.3.6 explores whether the inequalities in health outcomes and life expectancy are widening. In the UK, Jarvis and Wardle used an ‘indirect method’ to estimate that tobacco caused about two-thirds of the difference in risk of death across social class in men age 35–69 years.24 Prabhat Jha and colleagues reported in a four-country study (England, Wales, Poland and North America) that most social inequalities in adult male mortality during the 1990s were due to smoking.25 Bobak and colleagues reported similar results for Canada, Poland and the US, and contended that eliminating smoking would halve the social gradient in mortality among men.26 Professor Sir Michael Marmot, a public health epidemiologist and expert in health inequality, has been critical of these sorts of estimates, because some estimates have been derived by using lung cancer mortality as a proxy measure for smoking exposure, rather than using crude estimates to determine the contribution of smoking to socio-economic differences in mortality; hence they are likely to overestimate the importance of smoking.27 Authors of these studies have generally acknowledged the limits of indirect estimation. Blakely and Wilson and colleagues used direct methods to estimate the contribution of smoking to socio-economic and ethnic inequalities in mortality in New Zealand. Between 1996 and 1999, smoking contributed 21% to the gap between men aged 45–74 years with post-school qualifications and those with none. The corresponding figure for women was 11%.28 But other work suggested that only 5–10% of the larger inequality in mortality between Māori and non-Māori individuals was due to smoking, despite large differences in smoking prevalence.29 This estimate contrasted with a much greater estimated contribution by the Ministry of Health using Jha and colleagues’ indirect method.30 A study by Siahpush, English and Powles31 estimated that in Australia, smoking could account for just over one-third of the excess deaths in the 1990s that would otherwise be attributed to lower levels of education. Data on deaths among men aged 40–69 years taking part in a prospective cohort study in Melbourne between 1990 and 1994 showed that the association between education and mortality was greatly weakened after adjustment for smoking and the aetiologic fraction for low level of education was reduced from 16.5% to 10.6%. Vallejo and colleagues used data from the National Health Survey for England to estimate the contribution of lifestyle factors—obesity and smoking—to health inequalities across social classes (classified by level of income). Their findings, released in 2010, show income as a significant contributor to health inequalities, and that obesity and smoking contribute significantly, but less profoundly, to income-related inequalities in health. Obesity and smoking were estimated to contribute 1.2% and 3.2% to inequality respectively. Despite the prevalence of smoking declining over time, its effects on inequalities have slightly increased because of its over-representation among the lowest socio-economic groups and its effects on health.32 It is likely that indirect estimates of the contribution of tobacco smoking overestimate the importance of smoking by failing to take account of higher-than-average prevalence of behavioural and other risk factors in low-SES populations. Direct methods, however, may underestimate the importance of smoking because they do not take into account the long-term impact of smoking during pregnancy and the impact of smoking and exposure to tobacco smoke on diseases other than the ones for which epidemiological data are readily available. They also may not take account of the effects of spending on tobacco products on financial security and intergenerational poverty, which may help to perpetuate continuing high smoking rates in the children of smokers. These issues are explored further in Sections 9.4 to 9.8. Section: 9.3.5 Date of last update: 20 November 2012 Tobacco in Australia: 34 Facts and Issues Thun also discusses the difficulties in directly quantifying the contribution of smoking to disparities across social classes in a review of a study by Menvielle and colleagues,33 whose work estimated the degree to which smoking contributes to social class differences (classified by education level) in lung cancer incidences across a cohort of individuals from 10 European countries. Menvielle and colleagues concluded that smoking could account for about 50% of the inequalities in lung cancer risk due social group disparities in education. They noted these findings were unusual, and suggest residual confounding by smoking. They noted that in future studies, other risk factors in relation to smoking should be considered. Thun expressed the complexity in quantifying a direct relationship in this study because of changing demographics in Europe—the relationship between social class, smoking and lung cancer incidences have evolved and changed over time—noting, ‘it is extremely difficult for Menvielleet al. to disentangle the historical and birth cohort effects of lifetime smoking on lung cancer risk from any other factors that may have contributed to risk’.34 9.3.6 Are tobacco-related differentials in health status widening? In the US the socio-economic gap in life expectancy appears to be worsening. In people who had more than 12 years of education, life expectancy in the 1990s was about a year and a half greater than it was in the 1980s. In less educated people, life expectancy increased by only half a year. Much of the growing mortality gap can be attributed to the higher levels of decline in smoking-related diseases such as lung cancer and chronic obstructive pulmonary disease in more advantaged groups.35 Study authors attribute this to the larger declines in smoking prevalence in more advantaged compared with less advantaged groups that have been evident for some time in the US. Irvin and colleagues reported in 2009 that great disparities among socio-economic groups as well as racial groups exist for tobacco-related cancer incidences and mortality in the US. Disparities also ‘exist in access to, and quality of, cancer treatment’.36 The situation for Australia is much less clear-cut. A study published by the Australian Institute of Health and Welfare in 2006 indicated that death rates for cardiovascular disease reduced in all socio-economic groups between 1999 and 2003. There was a decrease in the size of the gap between the rates of death between upper and lower socio-economic groups for coronary heart disease and cardiovascular disease as a whole but an increase in the relative effect of disadvantage (the proportion by which the lowest socio-economic group was higher than the highest socio-economic group) for coronary heart disease, stroke and cardiovascular disease as a whole.11 In 2011, the Australian Institute of Health and Welfare reported death rates from cardiovascular disease have continued falling (based on AIHW mortality data from 2007). However, those of lower socio-economic status, the Indigenous and those living in remote areas of Australia still had the highest rates of hospitalisations and death from cardiovascular disease.37 Between 1982 and 2007, the age standardised mortality rates for lung cancer among Australian males decreased significantly, whereas mortality rates among females increased across this period. This trend is indicative of past smoking patterns. Lung cancer mortality rates for males peaked in the early 1980s, and since this time, have declined substantially; a reflection of declining smoking rates in males in the second half of the 20th century. In the case of women, females took up smoking later in the 20th century (increasing since the mid-1940s and reaching prevalence of about 33% in the mid–1970s), yet they smoked less than males. This pattern is reflected in female lung cancer mortality rates. These have been increasing over time, but more recently in the 1990s and 2000s, the increase has slowed compared with decades prior. Mortality rates from lung cancer show a clear social gradient. For the period 2003–2007, the highest mortality rates for all persons were among those living in the most disadvantaged areas in Australia. The mortality rate for males living in the least advantaged areas was 1.5 times the rate of mortality for males living in the most advantaged areas. Among females, the gap was slightly less, with 1.3 times the mortality rate in females living in the least advantaged areas compared with females living in the most advantaged areas.12 No data could be located on whether or not disparities in lung cancer mortality have widened. Between 1979 and 2006, mortality rates between low-SES groups and high-SES groups have narrowed in absolute terms among females for ischaemic heart disease (27 to 23 per 100 000). However, absolute differences for Section: 9.3.6 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 35 ischaemic heart disease widened in males across this period (52 to 63 per 100 000). Absolute differences for stroke between low and high-SES groups declined in males and females (16 to 13 per 100 000 among males and 13 to 7 per 100 000 among females). However relative declines were greater in high socio-economic groups compared with low socio-economic groups for both ischaemic heart disease (28% average five yearly decline in high socio-economic status males compared with 21% in low-SES males, and 30% and 21% for females respectively). For stroke, there was a 25% average five yearly decline in high-SES males compared with 21% in low-SES status males; 26% and 23% for females respectively).38 Section: 9.3.6 Date of last update: 20 November 2012 Tobacco in Australia: 36 Facts and Issues References 1. Turrell G, and Mathers C. Socio-economic status and health in Australia. Medical Journal of Australia. 2000;172(9):434–8. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/10870537 2. Australian Institute of Health and Welfare. Australia’s health 2010. Australia’s health series no 12, AIHW cat. no. AUS 122. Canberra: AIHW, 2010. Available from: http://www.aihw.gov.au/ publication-detail/?id=6442468376&tab=2 3. 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South Australia, Australia: The University of Adelaide, 2010. [viewed 7 May 2012]. Available from: http://www.publichealth.gov.au/inequality-graphs/monitoring-inequality-in-australia-australia-2010.html 19. Stringhini S, Sabia S, Shipley M, Brunner E, Nabi H, Kivimaki M, et al. Association of socioeconomic position with health behaviors and mortality. Journal of the American Medical Association. 2010;303(12):1159–66. Available from: http://jama.ama-assn.org/cgi/content/full/303/12/1159 20. Ou S, Ziogas A, and Zell J. Prognostic factors for survival in extensive stage small cell lung cancer (ED-SCLC): the importance of smoking history, socioeconomic and marital statuses, and ethnicity. Journal of Thoracic Oncology. 2009;4(1):37–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19096304 21. Soneji S, Iyer SS, Armstrong K, and Asch DA. Racial disparities in stage-specific colorectal cancer mortality: 1960-2005. American Journal of Public Health. 2010;100(10):1912-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20724684 22. Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJ, and Ezzati M. The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Medicine. 2010;7(3):e1000248. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20351772 23. Clarke R, Emberson J, Fletcher A, Breeze E, Marmot M, and Shipley M. Life expectancy in relation to cardiovascular risk factors: 38 year follow-up of 19 000 men in the Whitehall study. British Medical Journal. 2009;339:b3513. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19762417 24. Jarvis MJ, and Wardle J. Social patterning of individual health behaviours: the case of cigarette smoking. In: Marmot M, and Wilkinson RG, eds. Social Determinants of Health. Oxford, UK: Oxford University Press, 1999: Available from: http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780198565895.001.0001/acprof-9780198565895 25. Jha P, Peto R, Zatonski W, Boreham J, Jarvis M, and Lopez A. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. The Lancet 2006;368(9533):367–70. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140673606689757/ abstract Section: 9.3.6 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 37 26. Bobak M, Jha P, Nguyen S, and Jarvis M. Poverty and smoking. In: Jha P, and Chaloupka F, eds. Tobacco control in developing countries. Oxford: Oxford University Press, 2000: Available from: http://www.ingentaconnect.com/content/els/art00112 27. Marmot M. Smoking and inequalities. The Lancet. 2006;368(9533):341–2. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140673606689769/abstract 28. Blakely T, and Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981–84 and 1996–99. International Journal of Epidemiology. 2005;34(5):1054–62. Available from: http://cat.inist.fr/?aModele=afficheN&cpsidt=17204007 29. Blakely T, Fawcett J, Hunt D, and Wilson N. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? The Lancet. 2006;368(9529):44–52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16815379 30. Hunt D, Blakely T, Woodward A, and Wilson N. The smoking-mortality association varies over time and by ethnicity in New Zealand. International Journal of Epidemiology. 2005;34(5):1020–8. Available from: http://ije.oxfordjournals.org/cgi/content/full/34/5/1020 31. Siahpush M, English D, and Powles J. The contribution of smoking to socio-economic differentials in mortality: results from the Melbourne Collaborative Cohort Study, Australia. Journal of Epidemiology and Community Health. 2006;60(12):1077–9. Available from: http://jech.bmj.com/cgi/content/full/60/12/1077 32. Vallejo-Torres L, and Morris S. The contribution of smoking and obesity to income-related inequalities in health in England. Social Science & Medicine. 2010;71(6):1189-98. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20630642 33. Menvielle G, Boshuizen H, Kunst A, Dalton S, Vineis P, Bergmann M, et al. The role of smoking and diet in explaining educational inequalities in lung cancer incidence. Journal of the National Cancer Institute. 2009;101(5):321–30. Available from: http://jnci.oxfordjournals.org/content/101/5/321.long 34. Thun M. The evolving relationship of social class to tobacco smoking and lung cancer. Journal of the National Cancer Institute. 2009;101(5):285–7. Available from: http://jnci. oxfordjournals.org/cgi/reprint/101/5/285 35. Meara E, Richards S, and Cutler D. The gap gets bigger: changes in mortality and life expectancy by education, 1981-2000. Health Affairs. 2008;27(2):350–60. Available from:http:// content.healthaffairs.org/cgi/content/abstract/27/2/350 36. Irvin Vidrine J, Reitzel L, and Wetter D. The role of tobacco in cancer health disparities. Current oncology reports. 2009;11(6):475–81. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/19840525 37. Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series, no. 35. AIHW cat. no. CVD 53. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737418510 38. Page A, Lane A, Taylor R, and Dobson A. Trends in socioeconomic inequalities in mortality from ischaemic heart disease and stroke in Australia,1979-2006. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilit. 2011;[Epub ahead of print] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22007040 Section: 9.3.6 Date of last update: 20 November 2012 Tobacco in Australia: 38 Facts and Issues 9.4 The relationship between tobacco smoking and financial stress Tobacco use is both a contributor to and an outcome of financial stress.1 9.4.1 Spending on tobacco as a cause of financial stress The Australian Bureau of Statistics (ABS) regular survey of household expenditure2 provides interesting data about the relationship between smoking and financial stress. According to the ABS 2009–10 Household Expenditure Survey, households with lower-than-average income appear to spend (on average) slightly less on tobacco products per week than do higher-income households. However, average spending on tobacco products as a percentage of total weekly expenditure is higher among low- income households. In the lowest-income households expenditure on tobacco products as a proportion of total household weekly expenditure was over double that of the highest income households.3 In households where the main source of income is government pensions and allowances, the reported weekly expenditure for those on disability or carer payments was $20.98; among those on study or unemployment benefits, $24.77; and $18.92 for households receiving family support payments. This represents 2.9%, 3.5% and 2.3% of total weekly household expenditure among these groups respectively.3 Expenditure on tobacco products in single parent households was on Table 9.4.1 Average weekly expenditure on tobacco products average $16.83 per week, and those in state/territory housing reported among households in each income quintile, average expenditure of $17.67 per week.3 Australia, 2009–10, and as percentage of total In coupled households, those with children under five years of age spent household spending an average $7.80 per week on tobacco products and those with children aged 5–14 years spent an average $10.95. In comparison, couples (aged under 35 years) with no children spent an average $9.83 per week on Average Spending as tobacco in 2009–10.3 Economic weekly a % of total quintile amount spent household Research conducted on tobacco expenditure and its association with ($*) expenditure financial strain indicates that smokers are more likely to experience Lowest† 8.03 1.4 financial distress than non-smokers.1 Among smokers, factors like lower income, high nicotine addiction, a social circle of smokers and being of Second 12.18 1.5 younger age are associated with a likelihood of experiencing an instance of ‘smoking-induced deprivation’—whereby the smoker has reported Third 15.22 1.3 spending money on tobacco rather than on household essentials.4 Being Fourth 15.58 1.1 unable to afford enough food to maintain an active and healthy lifestyle (termed ‘food insecurity’) and its connection with low-income groups Highest 11.83 0.5 and high smoking prevalence has been shown in studies in the US population.5, 6 Borland and colleagues (2012) examined whether smokers who spend Source: Australian Bureau of Statistics 20113 more money on cigarettes are more likely to experience financial burden. * Current dollars: the price in the applicable year; no Collecting data on daily cigarette expenditure and using the outcomes adjustment has been made for inflation i ii † Includes a high proportion of households comprising older ‘smoking-induced deprivation’ (SID) and ‘financial stress’ (FS) , they single people on pensions, with a higher proportion of found that those who spent more on cigarettes were more likely to females than males i Smoking-induced deprivation (SID) defined as a time in the last six months when the money the respondent spent on cigarettes resulted in not having enough money for household essentials, such as food ii Financial stress (FS) defined as in the last month unable to pay any important bills on time (e.g. electricity) because of a shortage of money Section: 9.4.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 39 experience SID. They did not find evidence of an association between daily cigarette expenditure and financial stress; however smoking-induced deprivation was predictive of financial stress.7 9.4.2 Financial stress and its influence on smoking abstinence Research suggests that low-income smokers, or smokers experiencing financial stress, are less likely to quit and remain quit.8-10 Siahpush, Yong and colleagues (2009) used data from wave 4 of the International Tobacco Control Four-Country Survey to examine the association between financial stress and smokers’ interest in quitting, their attempts to quit and remaining quit. Smokers experiencing financial stress were more likely than others to want to quit smoking, but at follow-up, they were less likely to have made an attempt to quit smoking. Among the smokers who had made a quit attempt, financial stress was associated with less chance of smoking abstinence at follow-up.11 In a study of adults in Denmark, smokers of low socio-economic status described differing motives for quitting and reasons for relapse than smokers of high socio-economic status.12 Partos, Borland and Siahpush (2012) used the Australian cohort of the International Tobacco Control Four- Country Survey to examine the contribution of area-level socio-economic disadvantage in predicting a quit attempt, and achieving one-month and six-month abstinence from smoking. Interestingly, they found that smokers living in low socio-economic areas were no less likely to make quit attempts than those in high socio-economic areas. Almost 40% made quit attempts and this was unrelated to area-level disadvantage. The study found an independent association between area-level disadvantage and one month abstinence from smoking, but in a non-linear fashion. They also found evidence of an association with individual experience of smoking-induced deprivation and less probability of making quit attempts. The authors report that area-level disadvantage is not ‘consistently related to making quit attempts nor to medium-term abstinence success’; so area- level disadvantage presents ‘few barriers to smoking cessation’.13 9.4.3 Smoking cessation and the reduction of financial stress Data from the HILDA study also reveal that if smokers do manage to quit, their odds of experiencing financial stress reduce substantially when compared with those of continuing smokers. Data from the first, second and third waves of the study indicated that, on average, a smoker who quits could be expected to have a 42% reduction in the odds of experiencing financial stress.14 Another study, which used data from four waves of HILDA, showed that the odds of experiencing financial stress were 25% smaller for quitters than continuing smokers, and there was strong evidence of enhanced material wellbeing.15 Section: 9.4.3 Date of last update: 20 November 2012 Tobacco in Australia: 40 Facts and Issues References 1. Siahpush M, Borland R, and Scollo M. Smoking and financial stress. Tobacco Control. 2003;12(1):60–6. Available from:http://tobaccocontrol.bmj.com/cgi/content/full/12/1/60 2. Australian Bureau of Statistics. 6503.0 Household Expenditure Survey and Survey of Income and Housing: User Guide, 2009-10. Canberra: ABS, 2011. Available from: http://www.abs. gov.au/AUSSTATS/[email protected]/ProductsbyCatalogue/C571EA00F941140ECA2571880005BEE2?OpenDocument 3. Australian Bureau of Statistics. 6503.0 Household Expenditure Survey and Survey of Income and Housing: summary of results, 2009-10. Canberra: ABS, 2011. Available from: http:// www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/6530.02009-10?OpenDocument 4. Siahpush M, Borland R, and Yong H. Socio-demographic and psychosocial correlates of smoking-induced deprivation and its effect on quitting: findings from the International Tobacco Control Policy Evaluation Survey. Tobacco Control. 2007;16:e2 Available from: http://www.tobaccocontrol.com/cgi/content/full/16/2/e2 5. Armour B, Pitts M, and Lee C-W. Cigarette smoking and food insecurity among low-income families in the United States, 2001. Working paper no 2007-19. Atlanta, Georgia: Federal Reserve Bank of Atlanta, 2008. Available from: http://healthpromotionjournal.com/publications/journal/ib2008-07.htm 6. Cutler-Triggs C, Fryer GE, Miyoshi TJ, and Weitzman M. Increased rates and severity of child and adult food insecurity in households with adult smokers. Archives of Pediatrics & Adolescent Medicine. 2008;162(11):1056–62. Available from: http://archpedi.ama-assn.org/cgi/content/full/162/11/1056 7. Siahpush M, Borland R, Yong HH, Cummings KM, and Fong GT. Tobacco expenditure, smoking-induced deprivation and financial stress: results from the International Tobacco Control (ITC) Four-Country Survey. Drug and Alcohol Review. 2012;[Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22404640 8. 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 9. Siahpush M, and Carlin JB. Financial stress, smoking cessation and relapse: results from a prospective study of an Australian national sample. Addiction. 2006;101(1):121–7. Available from: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1360-0443.2005.01292.x 10. Dobson R. Poor more likely to smoke and less likely to quit. British Medical Journal. 2004;328(7445):914. Available from: http://www.bmj.com/cgi/content/full/328/7445/914-e 11. Siahpush M, Yong H, Borland R, Reid J, and Hammond D. Smokers with financial stress are more likely to want to quit but less likely to try or succeed: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction. 2009;104(8):1382–90. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2009.02599.x/full 12. Pisinger C, Aadahl M, Toft U, and Jorgensen T. Motives to quit smoking and reasons to relapse differ by socioeconomic status. Preventive Medicine. 2011;52(1):48-52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21047525 13. Partos TR, Borland R, and Siahpush M. Socio-economic disadvantage at the area level poses few direct barriers to smoking cessation for Australian smokers: findings from the International Tobacco Control Australian Cohort Survey. Drug and Alcohol Review. 2012;[Epub ahead of print]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22385265 14. Siahpush M, Spittal M, and Singh G. Smoking cessation and financial stress. Journal of Public Health. 2007;29(4):338–42. Available from:http://jpubhealth.oxfordjournals.org/cgi/ content/full/29/4/338 15. Siahpush M, Spittal M, and Singh GK. Association of smoking cessation with financial stress and material well-being: results from a prospective study of a population-based national survey. American Journal of Public Health. 2007;97(12):2281–7. Available from: http://www.ajph.org/cgi/content/abstract/97/12/2281 Section: 9.4.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 41 9.5 Smoking and intergenerational poverty Families where one or more parent uses tobacco not only suffer more immediate financial stress but also less financial security and a greater likelihood of poverty. Spending on tobacco products, loss of school time and income due to smoking-related disease and premature death of breadwinners over a lifetime must all substantially reduce 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 (Figure 9.5.1). High % of household Culture and socio-economic position expenditure on tobacco Smoking Intra-uterine Educational and Working conditions Income and assets during condition cultural conditions and income pregnancy Birth & childhood Adolescence Early adulthood Middle age Exposure to Role ETS modelling Low birth-weight, Smoking, diet, Job stress > Continued smoking growth retardation exercise cigarettes each day inadequate medical care Foetal programming Artherosclerosis CVD Reduced function/ Loss of for CVD and other QOL; early death breadwinner health problems Childhood illness and school absenteeism Figure 9.5.1 Socio-economic influences on cardiovascular disease from a life-course perspective Source: National Public Health Partnership 20011 Note: Adapted by M Scollo from Figure 6 in Preventing chronic disease: a strategic framework background paper1 9.5.1 Spending on tobacco products and its impact on financial security and wealth accumulation Higher rates of smoking and longer average times until cessation2 mean that lower socio-economic status (SES) smokers are more likely to suffer both frequent financial stress and longer periods of compromised living standards than their counterparts in the higher strata. Households where one or more adults smoke are less likely to have funds for discretionary spending on items such as house and contents insurance, motor vehicle insurance and health insurance.3,4 Medical problems, accidents Section: 9.5.1 Date of last update: 20 November 2012 Tobacco in Australia: 42 Facts and Issues and thefts of cars and other goods are therefore more likely affect these households significantly. Expenditure on health-risk behaviours are also more likely in smoking households— Siahpush and colleagues found odds of reporting expenditure on alcohol, drinking at licensed premises, and gambling were 100%, 50%, and 40% greater for smoking than for non-smoking households.4 Low-income families where one or more adults smoke may also be less likely to invest in superannuation, life insurance and insurance against loss of income.3 All of this translates to less security of income in older age, and less wealth to help adult children or to pass on to children after death. Smokers are also more likely to report a higher level of perceived income inequality, lower perception of relative material wellbeing and living in a community with a lower degree of trust and safety.5 Low-income families where at least one person smokes are less likely to be able to save a deposit to buy a dwelling, so that even controlling for different levels of age and income, they are much less likely to be purchasing and owning their own home.6 Australians’ average income doubled between 1984 and 2004; however house prices increased by 400%—making Australia one of the least affordable housing markets in the world. Nearly one-third of sole parents and single people were suffering from housing stressi during this time. A study by the National Centre for Social and Economic Modelling published in 2008 found that those buying their first home were particularly vulnerable to housing stress; they had had the lowest incomes, but paid the highest prices for houses, which put 62% of first-home buyers into housing stress.7 Jamsen and colleagues examined data from the Household Income and Labour Dynamics in Australia survey and found evidence of an association between being a smoking household (defined as having one smoker in the household) and having inadequate housing (though when adjusted for SES and age, this association was somewhat weakened).8 9.5.2 The long-term effects of smoking during pregnancy The higher rates of smoking during pregnancy among disadvantaged groups may well have far-reaching effects on the health and even the temperament of offspring well into adolescence and adulthood. While the effects of smoking on infant health are well known,9-11 a growing body of evidence suggests that foetal exposure to tobacco smoke also increases the risk of physical and behavioural problems in children and even in adult offspring.12, 13 These outcomes themselves contribute to social disadvantage. The effects of smoking during pregnancy are discussed in more detail in Chapter 3, Section 3.8. 9.5.3 Exposure to environmental tobacco smoke and school absence Children who suffer asthma and frequent respiratory disease are likely to miss more time at school than healthier children. Even controlling for SES and parental smoking status, exposure to secondhand smoke has been demonstrated to reduce school attendance14 and the productivity of parents who need to stay home to care for children.15 Poor school attendance is a very strong predictor of academic failure.16 Exposure to secondhand smoke may still reduce academic performance even where children don’t miss more school. A longitudinal analysis of educational achievement in children participating in the British National Child Development Study found that young people exposed to secondhand smoke at home were more likely to fail standardised UK O (Ordinary) level and A (Advanced) level achievement tests.17 This finding held regardless of prenatal exposure, school attendance and after controlling for SES. i The 19th AMP.NATSEM report defines housing stress ‘as households spending more than 30 per cent of their disposable (after tax) income on housing’. Section: 9.5.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 43 9.5.4 Parental example and smoking uptake: the cycle continues Children who grow up in households where adults 100 No parent smoking smoke are themselves more likely to take up smoking. One parent smoking 90 86 As discussed in detail in Chapter 6, smoking by one or Two parents smoking 80 73 more parents is a very strong predictor of uptake among 70 18, 19 children and smoking cessation reduces the chances of 60 58 20 children taking up smoking. % 50 21 40 Consistent with trends in other countries, Australian 29 30 teenagers are much more likely to experiment and to 21 20 smoke regularly if one or more of their parents smoke 11 13 10 4 7 than if neither of their parents smoke. Figures 9.5.2 and 0 9.5.3 plot the percentage of never smokers, experimenters never smoker experimental smoker current smoker and current smokers among secondary school smokers in Victoria according to parental smoking status. Figure 9.5.2 Among students aged 12–15 years, those who reported that Proportion of Victorian students aged 12–15 years who were never both parents smoked were more than twice as likely to have smokers, experimental smokers or current smokers among students experimented with smoking than students who reported with no parent smoking, one, or two parents smoking, Australia, 2008 that neither parent smoked. They were about three times more likely to be regular smokers than students who reported that neither parent smoked. Students of parents No parent smoking who did not smoke were much more likely to be a never 70 61 One parent smoking smokers compared with students who reported that both 60 Two parents smoking 22 parents smoked (86% compared with 58%). 50 46 39 Among students aged 16 and 17, those who reported that 40 36 38 % both parents smoked were more than twice as likely to 30 28 26 be regular smokers as students who reported that neither 20 16 parent smoked. Students who reported either one or two 11 parents were smokers had about the same likelihood of 10 having experimented with smoking. As seen in students 0 aged 12–15 years, students aged 16 and 17 who reported never smoker experimental smoker current smoker neither parent smoking were much more likely to report never smoking.22 Figure 9.5.3 The impact of parental smoking appears to be a long- Proportion of Victorian students aged 16–17 years who were never term one. Among Australian secondary school students smokers, experimental smokers or current smokers among students interviewed in 1985, compared with their peers who with no parent smoking, one, or two parents smoking, Australia, 2008 22 reported neither parent smoking, younger teenage boys Source: White and Smith (2010) who reported that both parents smoked were 50% more likely and younger teenage girls were 100% more likely to still be smokers 20 years later (males RR 1.53; 95% CI, 1.19–1.96 and females RR 1.99; 95% CI, 1.52–2.61).19 Keyes and colleagues reported that both genetic and environmental influences can increase the risk of cigarette use in the adolescent children, either biological or adoptive, of parents who smoke. They add that the effect of parental smoking on adolescents in biologically related families seems to be associated not only with cigarette use, but also with socially unacceptable behaviour (such as disruptive behaviour disorders, delinquency and preference for risk taking).23 Harvey reviews the work of Keyes and colleagues and notes that it is important to consider the influence of home environment/family dynamics (e.g. lack of parental supervision) and psychiatric diagnoses on the reported outcome of adolescents’ behaviour disorders and socially unacceptable behaviour. In addition, he notes that a higher socio-economic household is not necessarily protective against adverse home conditions.24 Section: 9.5.4 Date of last update: 20 November 2012 Tobacco in Australia: 44 Facts and Issues Macleod and colleagues reported parental social disadvantage was predictive of childrens’ tobacco and alcohol use. However some of this association appeared to be mediated by the greater experience of childhood behavioural and cognitive problems among the disadvantaged children.25 Absence of smoking restrictions at home is also associated with increased risk of smoking uptake by children. US studies26,27 have found that even after controlling for demographic factors and parents’ smoking status, children who lived in homes where smoking was banned were more than 20% less likely to take up smoking than children who lived in homes where smoking was allowed (see Section 5.14 for further information on the effects of smoking restrictions among young people, and see Section 9.1.7.2 for details on relative prevalence of smokefree homes by SES). Section: 9.5.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 45 References 1. National Public Health Partnership. Preventing Chronic Disease: a Strategic Framework. Background Paper. Melbourne, Australia: NPHP, 2001. Available from: www.nphp.gov.au/ publications/strategies/chrondis-bgpaper.pdf 2. Siahpush M, Heller G, and Singh G. Lower levels of occupation, income and education are strongly associated with a longer smoking duration: multivariate results from the 2001 Australian National Drug Strategy Survey. Public Health. 2005;119(12):1105–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16085150 3. Siahpush M. Unpublished analysis of 1998 National Drug Strategy Survey. 4. Siahpush M, Borland R, and Scollo M. Is household smoking status associated with expenditure on food at restaurants, alcohol, gambling and insurance? Results from the 1998-99 Household Expenditure Survey, Australia. Tobacco Control. 2004;13(4):409-14. Available from: http://tc.bmjjournals.com/cgi/content/abstract/13/4/409 5. Siahpush M, Borland R, Taylor J, Singh GK, Ansari Z, and Serraglio A. 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Sudden Infant Death Syndrome and parental smoking. Early Human Development. 2007;83(11):721−5. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/17881163 10. Salihu HM, and Wilson RE. Epidemiology of prenatal smoking and perinatal outcomes. Early Human Development. 2007;83(11):713-20. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/17884310 11. Aliyu MH, Salihu HM, Wilson RE, and Kirby RS. Prenatal smoking and risk of intrapartum stillbirth. Archives of environmental & occupational health. 2007;62(2):87-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18316266 12. O’Callaghan F, Al Mamun A, O’Callaghan M, Alati R, Najman J, Williams G, et al. Maternal smoking during pregnancy predicts nicotine disorder (dependence or withdrawal) in young adults - a birth cohort study. Australian and New Zealand Journal of Public Health. 2009;33(4):371–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19689599 13. Agrawal A, Scherrer J, Grant J, Sartor C, Pergadia M, Duncan A, et al. The effects of maternal smoking during pregnancy on offspring outcomes. Preventive Medicine. 2010;50(1–2):13–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20026103 14. Charlton A, and Blair V. Absence from school related to children’s and parental smoking habits. British Medical Journal. 1989;298(6666):90–2. Available from: http://www. pubmedcentral.nih.gov/picrender.fcgi?artid=1835401&blobtype=pdf 15. Gilliland F, Berhane K, Islam T, Wenten M, Rappaport E, Avol E, et al. Environmental tobacco smoke and absenteeism related to respiratory illness in schoolchildren. American Journal of Epidemiology. 2003;157(10):861–9. Available from: http://aje.oxfordjournals.org/cgi/content/full/157/10/861 16. Zubrick S, Silburn S, Gurrin L, Teoh H, Shepherd C, Carlton J, et al. Western Australian Child Health Survey: Education, Health and Competence. Perth, Western Australia: Australian Bureau of Statistics and the TVW Telethon Institute for Child Health Research, 1997. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4305.5September%20 1993?OpenDocument 17. Collins BN, Wileyto EP, Murphy MFG, and Munafò MR. Adolescent environmental tobacco smoke exposure predicts academic achievement test failure. Journal of Adolescent Health 2007;41(4):363-70. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1054139X07001826 18. Rainio S, Rimpelä A, Luukkaala T, and Rimpelä M. Evolution of the association between parental and child smoking in Finland between 1977 and 2005. Preventive Medicine. 2008;46(6):565–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18289657 19. Paul SL, Blizzard L, Patton GC, Dwyer T, and Venn A. Parental smoking and smoking experimentation in childhood increase the risk of being a smoker 20 years later: the Childhood Determinants of Adult Health Study. Addiction. 2008;103(5):846-53. Available from: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1360-0443.2008.02196.x 20. Farkas A, Distefan J, Choi W, Gilpin E, and Pierce J. Does parental smoking cessation discourage adolescent smoking? Preventive Medicine. 1999;28(3):213–8. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/10072737 21. Audrain-McGovern J, Rodriguez D, Tercyak KP, Neuner G, and Moss HB. The impact of self-control indices on peer smoking and adolescent smoking progression. Journal of Pediatric Psychology. 2006;31(2):139–51. Available from: http://jpepsy.oxfordjournals.org/cgi/content/abstract/31/2/139 22. White VM, and Smith G. Victorian secondary school students’ use of licit and illicit substances in 2008. Results from the 2008 Australian Secondary Students’ Alcohol and Drug Survey. Melbourne, Australia: Victorian Department of Human Services, 2010. Available from: http://www.health.vic.gov.au/aod/pubs/vsss.htm 23. Keyes M, Legrand L, Iacono W, and McGue M. Parental smoking and adolescent problem behavior: an adoption study of general and specific effects. The American Journal of Psychiatry. 2008;165(10):1338–44. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597022/ 24. Harvey L. Teen behaviors reflective of parental smoking. American Journal of Psychiatry. 2009;166(3):373. Available from:http://ajp.psychiatryonline.org/cgi/reprint/166/3/373 25. Macleod J, Hickman M, Bowen E, Alati R, Tilling K, and Smith G. Parental drug use, early adversities, later childhood problems and children’s use of tobacco and alcohol at age 10: birth cohort study. Addiction. 2008;103(10):1731–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18705686 26. Farkas AJ, Gilpin EA, White MM, and Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. Journal of the American Medical Association. 2000;284(6):717–22. Available from: http://jama.ama-assn.org/cgi/content/abstract/284/6/717 27. Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, and Ruel EE. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. British Medical Journal. 2000;321(7257):333-7. Available from: http://www.bmj.com/cgi/content/abstract/321/7257/333 Section: 9.5.4 Date of last update: 20 November 2012 Tobacco in Australia: 46 Facts and Issues 9.6 Smoking, ill-health, financial stress and smoking- related poverty among highly disadvantaged groups This section draws heavily on sources identified and material that appears in Chapter 1, Sections 1.8 to 1.10. In addition to the differentials in smoking among broad categories of socio-economic status, it is clear that smoking rates are even higher among many groups of highly disadvantaged people. The financial stress resulting from expenditure on tobacco products and the immediate and longer-term effects of smoking exacerbate the problems of many people grappling with intensely difficult personal challenges and social alienation due to a variety of life circumstances, events and choices. 9.6.1 People living in regional and remote areas of Australia About 31.2% of Australians live outside major citiesi; 68.8% live in major cities, 29% in regional areas and 2.2% in remote or very remote areas.2 People living in rural or remote Australia tend to work in more risky occupations and must travel long distances over country roads. They also are much more likely to smoke, be overweight or obese, to drink alcohol in hazardous quantities and to be physically inactive.3 Life expectancy decreases with increasing remoteness. People living in regional or remote areas of Australia are less likely to report being in ‘very good’ or ‘excellent’ health.3 The life expectancy of those living in regional areas is one to two years lower, and in remote areas, life expectancy is up to seven years lower compared with those living in major cities.4 Those living in regional and remote areas may face stressors in the form of drought, flooding, heatwaves, bushfires and outbreaks of plant disease, posing a health and economic burden on these populations. Psychological distress, such as depression, has been known to particularly affect these populations. Those living outside major cities are 1.1 times more likely to report suffering a mental disorder than those living in major cities.3 The 2007–08 ABS National Health Survey data show that those living outside major cities report higher rates of arthritis, asthma, diabetes, and heart, stroke and vascular disease.5 In 2010, smoking rates were 28.9% in remote/ very remote areas of Australia, 20.7% in outer regional areas, and 19.9% in inner regional areas. For those living in major cities, the prevalence rate was 16.8%.6 According to Australia’s Health 2010, participation rates in screening services, such as bowel, breast and cervical screening, did not necessarily show a gradient across geographical areas. Participation rates in the BreastScreen Australia program were significantly higher in those living in regional areas, outer regional and remote locations compared with those in major cities (the exception was very remote areas, where participation rates were significantly lower). Although participation rates in the National Cervical Cancer Screening Program were similar (about 61%) across major cities, inner regional and outer regional locations, it was significantly lower in remote and very remote locations (54.6% and 59.0% respectively). Participation in the National Bowel Cancer Screening Program also showed varying uptake by geographical areas. Inner regional and outer regional locations showed significantly higher levels of participation than major cities (1.1 and 1.03 times that of major cities respectively), while participation was significantly lower in very remote locations (0.7 times that of major cities).3 Living some distance from major population centres, rural populations often lack access to specialist medical and other health services. Because health professionals are in such short supply in rural and remote areas, it is often difficult to find time for preventive health activities. The National Strategic Framework for Rural and Remote Health sets out goals: i As classified by the Australian Standard Geographical Classification (ASGC)1 Section: 9.6.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 47 < 9.6.2 People born overseas At 30 June 2010, data on the estimated resident population of Australia (22.3 million people) report that 27% of the population were born overseas (6.0 million people).9 Although migrants to Australia come from more than 200 different countries, the majority of overseas-born residents hail from the UK.3 Moving countries profoundly changes peoples’ lives. For many it provides escape from poverty and violence; it almost always gives people the chance, if not to improve their immediate economic situation, to at least provide a much better future for their children. With this may come great optimism and sense of purpose, and strong bonds with and support from others living nearby from the same cultural background. Immigrant populations generally enjoy better reported health and lower rates of disability and hospitalisation than those reported by people born in Australia.10 Rates of mortality for some diseases are higher in some immigrant groups compared with Australian- born residents, for example, lung cancer in people born in the UK, the Netherlands and Ireland; coronary heart diseases in people born in Poland; and diabetes in those born in Germany, Greece, India, Italy, Lebanon and Poland.3,11 But immigration can also result in quite extreme social and cultural isolation and many people who move to Australia from non-English speaking countries are further disadvantaged by lack of access to information, and limited employment opportunities due to less facility with English and lack of recognition of educational and professional qualifications gained overseas. Even with these countervailing forces, the prevalence of mental health problems is not higher in people born in non-English speaking and other countries outside Australia. The National Survey of Mental Health and Wellbeing showed that persons born overseas were considerably less likely to report ever having a mental disorder (defined as lifetime mental disorder) (28.9 per 100 000) than persons born in Australia (48.7 per 100 000) and other predominantly English-speaking countries (50.2 per 100 000). Among those diagnosed at some point with a mental disorder and suffering symptoms recently (12 months prior to the survey), persons born overseas had much lower prevalence compared with those born in Australia and predominantly English-speaking countriesi.3,12 However, there is evidence to suggest that those who speak a language other than English at home are less likely to participate in health services than persons where English is the predominant language spoken at home. Between 2005 and 2006, 45% of females aged 50–69ii years of age who spoke a language other than English participated in breast cancer screening. In comparison, participation rates of females of the same age bracket whose main language spoken at home was English were 59%. In addition, persons who spoke a language other than English at i Unpublished Australian Institute of Health and Welfare analysis from the Australian Bureau of Statistics 2007 National Survey of Mental Health and Wellbeing. Reported in Australia’s Health 20103. Australian Institute of Health and Welfare. Australia’s health 2010. Australia’s health series, no 12, AIHW cat. no. AUS 122. Canberra: AIHW, 2010. Available from: http:// www.aihw.gov.au/publication-detail/?id=6442468376&tab=2 (p271) ii 50–59 years of age is the target age bracket for breast cancer screening. Section: 9.6.2 Date of last update: 20 November 2012 Tobacco in Australia: 48 Facts and Issues home were less likely to use a health service for a lifetime mental disorder (26 per 100 000 compared with 48 per 100 000 in predominantly English speakers)i.3, 12 So does the migrant experience translate into greater risk of smoking? For daughters of parents coming to Australia from Asian, African and Middle Eastern countries where female smoking rates are generally very low, contact with other Australian girls may result in a greater risk of smoking uptake.ii Further, among migrants who are already smokers, the stresses associated with establishing a new life in Australia may work against success in quitting. However, equally it is also possible that moving to Australia increases the likelihood of quitting in those groups who come from countries with less developed tobacco-control policies. As a demonstration of this effect, a study of Asian immigrants to California in the US (a jurisdiction with a strong history in tobacco control), found that Chinese and Korean immigrants to California had much higher quit ratios than among the populations in their respective homelands. The Chinese immigrants in California quit at roughly seven times the rate of Chinese in China, and Koreans in California three times that of Koreans in Korea. The difference in cessation rates was accounted for by the much higher number of quit attempts made by those living in California as opposed to their counterparts in their homeland, suggesting that time spent in an environment with significantly different social norms towards smoking was a driver for quit attempts.14 Overall it would seem that being an immigrant or speaking a language other than English is not a risk factor for smoking. People from non-English speaking backgrounds are less likely to smoke than those where the major language spoken at home is English.6 Data from the National Drug Strategy Household Survey indicate current smoking prevalence for personsiii who speak a language other than English at home is 11.6%, compared with 18.4% of those whose main language spoken at home is English. There were a high proportion of non-smokers in homes where English was not the main language spoken (80.4%), compared with predominantly English-speaking households (55.5%). The National Health Survey reports similar findings, where prevalence of smoking was 12.2% among thoseiv who predominantly speak a language other than English. People migrating to Australia after 1996 are only slightly less likely to be smokers than those arriving prior to 1996, and are also less likely to smoke than the Australian population as a whole.5 However, it also has to be recognised that people in some cultural and linguistic communities smoke at very high rates indeed. Studies from the 1990s indicated that among the Arab-speaking population in Sydney, more than 50% of both males and females reportedly smoked;15 among the Sydney-based Lebanese community, about 49% of males and 29% of females were smokers16. Male members of the Vietnamese community in Sydney had smoking rates of 53%.17 The ‘45 and Up Study’ in Australia demonstrates how smoking prevalence can vary across cultural sub-groups. It examined smoking characteristics of Australian migrants compared with those of Australian-born residents aged 45 years and older and found that compared with Australian-born men, a higher proportion of men born in Europe, North Africa and the Middle East were current smokers. Compared with Australian-born women, a lower proportion of women from East and Southeast Asia were current smokers and a higher proportion of women from New Zealand and the UK/Ireland were current smokers. Among women born in Asia, the risk of smoking increased significantly the younger they migrated to Australia. The duration smoked and amount smoked per day was primarily lower among migrants than Australian-born persons.18 i Unpublished Australian Institute of Health and Welfare analysis from the Australian Bureau of Statistics 2007 National Survey of Mental Health and Wellbeing. Reported in Australia’s Health 20103. Australian Institute of Health and Welfare. Australia’s health 2010. Australia’s health series, no 12, AIHW cat. no. AUS 122. Canberra: AIHW, 2010. Available from: http:// www.aihw.gov.au/publication-detail/?id=6442468376&tab=2 (p273) ii Researchers, however, have demonstrated an inverse social gradient among women of Turkish and Moroccan background who have immigrated to The Netherlands.13. Nierkens V, de Vries H, and Stronks K. Smoking in immigrants: do socioeconomic gradients follow the pattern expected from the tobacco epidemic? Tobacco Control. 2006;15(5):385–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16998173 iii Persons aged 14 years plus iv Persons aged 15 years plus Section: 9.6.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 49 A study of Arabic-speaking patients seen in the general practice setting in New South Wales found that of more than 1000 patients seen by the general practitioner, 29.7% were smokers. Smokers were also more likely to report poorer overall health and high nicotine dependence. Nicotine dependence was highest in Arabic-speaking males.19 Further studies from New South Wales show that while school children within families from high-smoking communities have a lower prevalence of smoking than their counterparts from English-speaking homes,20 older teenagers are more likely to take up smoking once parental controls reduce.16, 21 While being born overseas in itself is not a risk factor for smoking, being a member of a community where smoking is common may increase health and financial problems of families affected. In Canada, a study of overseas-born children found that the likelihood of smoking increased with the years spent living in Canada, suggesting that the unhealthy behaviours arose after time in their new homeland.22 A similar finding was made in the US, where a survey of Hmong American youths and adults found that among youth, 15% reported daily smoking use and 32% reported ever smoking. The odds of ever use of tobacco increased as the percentage of life lived in the US increased.23 As with other disadvantaged smokers, smoking must also contribute to financial stress. With prices of tobacco products much higher in Australia than in their countries of birth, spending on tobacco products among recent immigrants who smoke must significantly reduce funds available for family goals such as saving for a home, education in a private school and assisting other family members both in Australia and overseas. A US study examined the influence of financial strain on quitting success among a group of smokers from Latino, African American and Caucasian background. They found that greater financial strain at the outset was significantly associated with reduced odds of abstinence at 26 weeks post-quit. They concluded that greater financial strain predicted lower cessation rates among racially/ethnically diverse smokers.24 People from cultural backgrounds where smoking is prevalent may face cultural resistance to quitting due to traditional beliefs and attitudes to smoking.15 Continued smoking by family and friends may make it harder to contemplate quitting and increase chances of relapse in those who give it a go. People from culturally and linguistically diverse (CALD) backgrounds also lack access to information due to language barriers. Providing education and support to Australians with different cultural backgrounds provides particular challenges for public health policy, as has been recognised by the National Tobacco Campaign.8 9.6.3 Lone parents, especially lone mothers In 2009–10, one in five children aged younger than 17 years (20%) had a natural parent living elsewhere (about one million children). For the majority of these children (81%), this person was their father. Almost three-quarters of children with a parent living elsewhere were in one-parent families.25 Lone mothers and their children are one of the most disadvantaged groups in many countries26 and suffer higher risks of poverty and ill-health than other family types.27,28 Lone parents tend to have higher levels of unemployment, in part due to caring responsibilities, and are more likely to experience financial hardship.29 Rahkonen and colleagues reported the more the economic hardship the more smoking was prevalent among subjects of their study in Finland. The association between economic hardship and lone parenthood was significant independent of other factors such as education, occupational social class, household disposable income, housing tenure or social relations for both men and women.30 In Australia in 2009–10, three in five (59%) of lone parent households with dependent children were classified as having ‘low economic resources’.i One-parent households accounted for 6% of all households, but made up 18% of low economic resource households.25 In the same year, expenditure on tobacco products in single parent households with dependent children was on average $16.83 per week.31 In comparison, coupled households with dependent children spent $11.86 per week.31 i Where the average weekly equivalised adjusted disposable household income was $465. For a full explanation see Australian Bureau of Statistics, 4102.0 Australian Social Trends, March quarter 2012.25. Australian Bureau of Statistics. 4102.0 - Australian Social Trends, March quarter, 2012. Canberra: ABS, 2012. Available from: http://www.abs.gov.au/ausstats/[email protected]/ mf/4102.0 Section: 9.6.3 Date of last update: 20 November 2012 Tobacco in Australia: 50 Facts and Issues Australian research conducted in the early part of the 2000s found that the overall prevalence of smoking among lone mothers was about 46%, with those younger in age (18–29 years) reporting the highest prevalence (59%).32 Lone mothers who were younger, less educated, received government pension/benefits, occupied rental housing, or who lived in more disadvantaged areas were more likely to smoke than others. A strong ‘lone mother effect’ remained after controlling for socio-economic variables. The odds of smoking for lone mothers were 2.4 times greater than for married mothers (95% CI: 2.0–2.9) and twice as large as those for women living alone (95% CI: 1.6–2.4).33 As highlighted by Hilary Graham in her extensive research and writing about smoking in lone mothers in the UK,27,34-40 smoking status among this group is associated not just with the difficult circumstance they face in the present,41 but also by ‘longer term biographies of disadvantage.’34 Lone mothers are much less likely than mothers with partners to quit or suspend smoking during pregnancy. And mothers who continue to smoke during pregnancy are much more likely to report having a difficult, fussy baby, further adding to the stress of looking after children without a partner present.42,43 In 2010, the National Drug Strategy Household Survey reported current smoking prevalence in single-parent households with dependent children was 36.9%. This was over double the current smoking in coupled households with dependent children, where prevalence was 17.9%. Single-person households without children had a current smoking prevalence of 23.8%. Lone households with dependent children also smoked more cigarettes than other households with dependent children, with an average of 110 cigarettes smoked per week, compared with an average of 95.4 cigarettes smoked per week in households headed by a couple.6 Gartner and Hall reported that in Australia between 2001 and 2010 the proportion of households containing a smoker and a child under the age of 15 declined both in lone parent households and households headed by a couple. However the decline was more profound in two-parent households, with about half of lone-parent households with dependent children still smoking in 2010. Lone-parent households with dependent children had a greater percentage increase between 2001 and 2010 in only smoking outdoors while at home, compared with two-parent smoking households. However, lone-parent households were still half as likely to smoke only outdoors as two-parent households.44 Table 9.6.1 Prevalence of smoking in households containing a child under the age of 15 overall and according to household structure, 2001–10 % change between 2001 2004 2007 2010 2001 and 2010 % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI Smoker(s) in household 44.3 (42.7–45.9) 40.8 (39.5–42.1) 37.3 (35.6–39.0) 34.6 (33.1–36.1) –21.9 (–26.3––17.5) Couple 40.3 (38.6–42.1) 36.8 (35.4–38.3) 33.5 (31.7–35.3) 30.5 (28.8–32.2) –24.3 (–29.6––19.0) Single 59.0 (54.8–63.1) 58.0 (54.5–61.5) 56.8 (51.8–61.8) 51.8 (46.7–56.9) –12.2* (–22.8––1.5) Smoker(s) in smoking 55.6 (53.2–58.0) 69.5 (67.6–71.4) 78.5 (76.1–80.9) 85.4 (83.5–87.3) 53.6 (46.1-61.1) households only smoke outdoors Couple 60.0 (57.3–62.8) 73.7 (71.6–75.9) 81.7 (79.1–84.3) 89.7 (87.7–91.7) 49.4 (41.7–57.0) Single 42.4 (37.0–47.9) 55.0 (50.3–59.6) 66.2 (59.8–72.5) 72.6 (66.3–79.0) 71.3 (44.7–97.9) Source: Gartner and Hall (2012)44 * Result should be interpreted with caution as Relative Standard Error lies between 25% and 50%. Children who live in households with a smoker suffer from more respiratory diseases45 and respiratory illnesses occur more frequently and more severely in those exposed to environmental tobacco smoke.46 Children of lone parents who smoke are also much more likely than children in two-parent families (and than children of lone parents who do not smoke) to begin smoking as teenagers,47–49 thus the effects of smoking are perpetuated across the generations. Section: 9.6.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 51 9.6.4 People with mental illnesses Mental health problems are common within the Australian population. Mental disorders are the third leading ‘broad cause’ of Australia’s disease burden, behind cancer and cardiovascular disease.3 The National Survey of Mental Health and Wellbeing indicates one in five Australians between 16 and 85 years have suffered from one or more of the common mental disorders in the 12 months before the survey (categorised by mood disorders, such as depression, anxiety disorders and substance use disorders). Among young people aged 16–24 years, as many as one in four persons reported a mental disorder at some time in the preceding 12 months.3,12 The National Drug Strategy Household Survey reports that smokers were twice as likely as non-smokers to report being diagnosed with, or treated for, a mental illness. Smokers were also more likely to report high or very high levels of psychological stressi in the four-week period before the survey.6 9.6.4.1 Mental illness and disadvantage People with serious mental illnesses are very seriously disadvantaged in employment, housing, and just about every sphere of life. They report higher rates of unemployment, are at a greater risk of homelessness, and are more likely to have lower levels of educational attainment than the general population.50 Current tobacco use is strongly associated with a range of other substance use and mental health problems.51,52 In the US and Australia, adults reporting with mental disordersii in the 12 months before the survey smoked at almost double the rate of adults without mental disorders.54 Mental health problems are higher in the other highly disadvantaged groups discussed in this section. 9.6.4.2 Smoking among those with long-term mental health or behavioural problems Refer to Chapter 7, Section 7.12 for a full discussion on smoking prevalence among those who report mental health problems. 9.6.4.3 Smoking among those with serious psychiatric illnesses The 2010 National Survey of Psychotic Illness indicates 64 000 Australians aged 18–64 years have a psychotic illness (4.5 cases per 1000 in the 12-month period to March 2010). Psychotic illnesses can include schizophrenia, schizoaffective disorders, bipolar disorder and depression. The most common reported disorder was schizophrenia, accounting for 47% of all psychotic disorders. Schizophrenia accounted for more than half of psychotic disorders among males (56.3%) and one-third of psychotic disorders among females (33.2%).50 The survey indicates smoking rates among Australians with a psychotic illness were 67.2% in 2010, declining only a little since 1997–98, when current smoking prevalence among this population was 68.9%. Sixty-six per cent of people with psychosis reported smoking an average of 21 cigarettes per day. 50 A review of 42 international studies in 20 nations found an average smoking prevalence among people with schizophrenia of 62%.55 Diaz and colleagues reported from their study of smoking prevalence among patients with bipolar disorder, schizophrenia and major depression that daily smoking rates among those with major depression i Refers to level of anxiety and depressive symptoms a person may have felt in the preceding four-week period.25 Ibid. ii As classified by the International Classification of Diseases, 10th edition (ICD-10).53. World Health Organization. International Classification of Diseases (ICD). Geneva: WHO, 2012. [viewed 5 May 2012]. Available from: http://www.who.int/classifications/icd/en/ Section: 9.6.4.3 Date of last update: 20 November 2012 Tobacco in Australia: 52 Facts and Issues were 57%, and 66% among those with bipolar disorder. Among patients with schizophrenia, daily smoking prevalence was as high as 74%.56 The interaction between tobacco use and mental illness is complex and likely to reflect a number of factors; the complexity of these interactions and associations has been well examined among adults as well as among adolescents and children.52,57-59 Swendson and colleagues set out to examine mental disorders and risk factors for later onset of nicotine, alcohol and drug use, abuse and dependence. Behavioural disorders and pre-existing substance abuse were predictive of later transition to substance abuse. They concluded there was significant prospective risk associated with baseline mental disorders for the onset of nicotine, alcohol and illicit drug dependence with abuse over the study follow-up period (10 years after baseline). However they noted the complexity in these associations, in that the magnitude of associations varied across categories of mental disorders and there were differences observed across mental disorder and the onset of use, abuse and dependence with abuse. For example, their analysis suggested that certain conditions, such as anxiety or additional substance use disorders, play a fairly stronger role in the initial onset of daily smoking or drug use than in the onset of dependence. In comparison, many forms of disorder were more strongly associated with transitions to dependence on alcohol than with the onset of use or abuse of alcohol.60 Smith and colleagues reported patients with a first episode of psychosis actually initiated smoking before the first signs of illness (psychosis), suggesting smoking may not have been a response to the early signs of the illness. They reported subjects were vulnerable to the same predictors of smoking uptake as the general population, particularly prenatal tobacco exposure, which is also known to be connected with other medical, cognitive and behavioural problems.61 People with mental health illnesses who live in institutions have higher rates of smoking than those living in the community.62 For inpatients in an institution, environment may reinforce smoking behaviour.63 Many patients report smoking more due to boredom.64 Smoking may also be seen as a means of reclaiming a degree of self-determination and autonomy in the face of disempowerment.65 Although most patients with a psychiatric condition report that they smoke for the same reasons as other smokers (including ‘addiction’, for ‘relaxation’ and to ‘calm down’)66–68 there is evidence that nicotine may serve for some as a form of self-medication to ameliorate symptoms of certain mental illnesses, or to alleviate side effects of prescribed medication.62,66,67 9.6.4.4 Financial stress among those with mental illness who smoke The interaction between poor mental health and poverty and/or financial stress is well known; understanding its mechanism was a subject of study for Jenkins and colleagues. They found that the most disadvantaged, by low income, were more likely to have a mental disorder. Twenty-three per cent of subjects with a mental disorder were in debt, compared to 8% of those without a mental disorder; the more debt the subjects had, the more likely they were to have some form of mental disorder. They concluded that low income and debt were associated with mental illness but the effect of income was mediated largely by debt.69 In Australia in 2000, it was estimated that people with a psychotic illness who smoked and were in receipt of a disability support pension spent more than one-third of their pension on tobacco products, and contributed a total of about $111 million each year in tobacco taxes to the Australian Government. According to this study, smoking contributes to the vicious cycle of poverty and disadvantage in which many mentally ill people are trapped.65 In 2010, the Australian national survey of people living with psychotic illness reported 85% of persons with a psychotic illness obtained their main source of income from government payments. One-third of those with a psychotic illness had been in paid employment in the past year (32.7%) and one in five was employed at the time of the survey interview (21.5%). In comparison, about 72% of the general working age population (age 15–64 years) were employed in July 2010. One in twenty with a psychotic illness were homeless at the time of interview, one in ten (11.0%) were in supported accommodation, and only 15% had some form of private health insurance. Section: 9.6.4.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 53 Smoking status and gambling have also been associated with psychiatric symptoms.70 Smoking prevalence has been reported to be very high among people who call helplines for problem gamblers (over 43% in one US study).71 9.6.4.5 Preventable diseases among those with mental illness who smoke The higher rates of smoking among people with mental health problems and mental illnesses means that they are more likely to suffer all the various health problems associated with tobacco use. Those with psychotic illnesses report higher rates of asthma, heart and/or circulatory conditions, arthritis, diabetes, kidney disease and stroke.50 People with mental illness may not be as frequently or intensively counselled about preventive health issues by health practitioners very much focused on managing immediate symptoms of mental illness.72 Studies report, however, that risks of cardiovascular disease can be reduced by interventions to stop smoking among patients with mental illness.73,74 US research has indicated a 20% reduction in life expectancy among people suffering from schizophrenia,75 with heart disease being the most common cause of death.76 9.6.4.6 Barriers to cessation among those with mental illness Refer to Chapter 7, Section 7.12.4 for a full discussion on smoking prevalence among those who report mental health problems. 9.6.5 People with alcohol and drug problems Material in this section draws heavily on a comprehensive review produced by Baker et al published in the Drug and Alcohol Review in 2006.77 People with mental health problems are much more likely to suffer from alcohol and other drug problems,78 including smoking,79 and tobacco use commonly co-exists with other drug use (see Chapter 1, Section 1.10.6). The National Drug Strategy Household Survey reported the diagnoses or treatment for a mental illness was much more common in those who had used illicit drugs in the last 12 months (18.7%), and in the last month (20.4%) compared with those who had not used illicit drugs in the past 12 months (10.8%). Illicit drug users also had higher levels of psychological distress than non-users.6 A US study examined psychiatric co-morbidity associated with nicotine addiction among alcohol-dependent respondents in the general population. Forty-eight per cent of the alcohol-dependent respondents reported nicotine dependence. In addition they reported ‘higher lifetime rates of panic disorder, specific and social phobia, generalised anxiety disorder, major depressive episode, manic disorder, suicide attempt, antisocial personality disorder and all addictive disorders than those without nicotine dependence’.80 Most individuals presenting for treatment for substance use disorders smoke tobacco as well.77 Australian research68,79 shows that in this population, smoking rates range from 68% to 90%.68 Among mentally ill inpatients with co-existing alcohol and other drug problems, smoking rates as high as 90% have been observed.68 The relationship between tobacco and other drug use is complex, and may be subject to genetic and neurobiological determinants, as well as psychological and social influences.81–83 As pointed out by Baker and colleagues, those with substance abuse problems who also smoke tobacco ‘... are at particularly high risk of experiencing harm as a consequence of a typically heavier pattern of tobacco use…and due to the synergistic effects of these substances. It has been estimated that the combined health risks of smoking and alcohol use are 50% higher than the sum of their individual risks. For example in the Section: 9.6.5 Date of last update: 20 November 2012 Tobacco in Australia: 54 Facts and Issues case of oesophageal cancer, the excellent solvent properties of alcohol may take the carcinogen in tobacco smoke to basal layers. In addition, people with severe alcohol and drug dependence problems are more likely to die from tobacco-related causes such as coronary heart disease, cancer, stroke and chronic lung disease, than from caused related to the use of any other drugs.’ Baker et al 200677 (p87) Cessation interventions tailored to the needs of poly-drug users are discussed in Chapter 7, Section 7.12.5. 9.6.6 The homeless Homelessness is defined as lacking adequate access to safe and secure housing. In 2010, 1.1 million Australian adults (7% of the 16.8 million adult population living in private dwellings) had experienced homelessness at some time in the previous 10 years. They were mostly younger adults (18–34 years) who had lower levels of education, were more likely to have been unemployed in this period, derived their main income from government pensions or allowance and had experienced financial stress compared with those who had not been homeless. They were also more likely to report disability or a long-term health condition. Reports of psychological disability or restriction in the homeless were four-fold compared with those who had never been homeless (22% compared with 5%).25 Individuals experiencing homelessness have a poorer health status than the general population, with the ‘street homeless’ (those usually dwelling on streets or in parks, in derelict buildings or other temporary shelters) being the worst affected.84 Melbourne-based research has shown a greatly elevated prevalence of smoking among the homeless (77%), with street homeless reporting higher rates of 93%.84 People who live ‘rough’ are unlikely to see media advertising about the dangers of smoking. Unrestricted smoking outdoors is likely to result in the development of high levels of dependence on tobacco-delivered nicotine. Research conducted by Apollonio and colleagues suggest that the mentally ill and homeless have been the subject of cigarette promotion and marketing in the past.85 9.6.7 Prison populations At 30 June 2011, there were 29 106 prisoners (sentenced and unsentenced) in Australian prisons. Of the total prisoner population, 7% (2028) were female and approximately 8 in 10 (79% or 23 082) were born in Australia.86 The prevalence of smoking in the prison population is far higher than among the general population,87,88 and tobacco use is commonly accepted as part of prison life.88 Prison entrants in Australia are more than three times as likely as those in the general population to be daily tobacco smokers (74% compared with 20%).3, 5 It is not unusual for tobacco to be used as currency in gambling or other trade.88 Papododima and colleagues found about 80% of prisoners in their study identified as current smokers, with 43% reporting deterioration of smoking habits when incarcerated. Heavy smoking was linked to past adverse childhood events and personality traits, such as impulsivity, among prisoners.89 Research undertaken in 2001 examining smoking among New South Wales prisoners found that 78% of male and 83% of female inmates were smokers.88 Most (95%) inmates smoked roll-your-own cigarettes, a far higher proportion than that seen in the rest of the population.88 Forty-one per cent of prisoners who smoked reported that they smoked more heavily in prison than when in the community. Illicit drug use was closely connected to tobacco use, with about 90% of individuals who had ever injected drugs, or used cannabis, being smokers as well.88 Eighty- six per cent of inmates aged under 25 were smokers, compared with 64% of prisoners aged over 40. Prisoners who smoked were less likely to have completed their schooling. A small number of smokers had started smoking in prison (7%).88 A 2008 study of prisoners in three metropolitan intake prisons in Adelaide found many prisoners used multiple substances, with the six most common substances used at high and moderate risk levels being tobacco, cannabis, Section: 9.6.7 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 55 amphetamines, opiates, alcohol and sedatives. Of these, tobacco was the mostly commonly used substance among male and female prisoners.90 The elevated smoking rates in the prison population reflect, to a large extent, increased likelihood of disadvantaged socio-economic backgrounds in inmates.91 Indigenous people make just over a quarter (26% or 7656) of the total prisoner population.86 Drug users and the less educated are over-represented in the prison system, as are those suffering mental disorder.92 Younger prison entrants (age 25–34 years) in Australia were more likely than their counterparts in the general population to have asthma (15% compared with 10%) and diabetes (2% compared with 1%). The high rates of diabetes are likely linked to the large proportion of Indigenous Australian prisoners, where prevalence of diabetes in this group is higher than non-Indigenous Australians. Prisoners aged 35–44 years were also twice as likely to have cardiovascular disease compared with those aged 35–44 years in the general population.3,5,93 The 2007 National Survey of Mental Health and Wellbeing reported incidence of mental disorders among individuals who had at some time been imprisoned was greater than among those who had not (41% compared with 19%).12 Findings from the National Prisoner Health Census showed a similar pattern of mental health problems among prison entrants. A history of mental health problems was more common among female prison entrants and close to a third of prison entrants were referred to prison mental health services as a result of their initial health assessment. More than one-third of the 549 prisoner entrants reported ever being told by a doctor, psychiatrist, psychologist or nurse that they had a mental disorder.3,93 Exposure to secondhand smoke in prisons must be very high, even though smoking has been increasingly restricted in indoor areas.94 Ill-health due to tobacco and spending on tobacco products must create significant challenges for prisoners trying to secure a job and a safe and secure place to live once they are released from prison. Both these factors reduce the chances of reoffending and are crucial for the successful transition to life outside prison. Thibodeau and colleagues reported smoking intention prior to release from prison was predictive of smoking behaviour post-release. Belief in improved health after release was associated with non-smoking at release from prison.95 Prisoners are part of the key target group in the Australian Government’s National Tobacco Campaign, where a $27.8 million anti-smoking social marketing campaign is being implemented to target tobacco use in high-risk and high-need groups.8,96 9.6.8 Veterans Tobacco use has historically been a part of defence force culture, with tobacco being provided and promoted to troops in the past.97– 100 Stress and trauma associated with war deployment has been associated with the uptake of smoking, resumption of smoking and overall high rates of smoking compared with the general population.101,102 More recently, research has been conducted to determine how to effectively denormalise smoking in the military and reduce barriers to smoking cessation.103 In 2006, the ‘Your Lives, Your Needs’ survey was conducted to assess the health and wellbeing of Australia’s Department of Veterans’ Affairs veteran community. It surveyed two groups:Veterans’ Entitlements Act 1986 clients (80% were aged 65 years plus) and Safety, Rehabilitation and Compensation Act 1988 clients (almost 60% were aged under 45). The older clients (65 years plus) were less likely to rate their health as very good or excellent compared with general community aged 65 years of age plus (21% compared with 36%). Among the younger clients, the difference was much more marked, with only 10% of veterans reporting their health as very good or excellent, compared with over 60% in general population aged 45 years and under. In 2009, 50 000 Department of Veterans’ Affairs clients had accepted one or more mental health disability claims associated with their participation in war or defence service. The most common reported conditions were post-traumatic stress disorder, anxiety, substance abuse and depression.3 While military personnel have one of the highest rates of smoking among adults in the US,104–106 a more recent qualitative study of US defence personnel found that the primary strength of its tobacco-control program was Section: 9.6.8 Date of last update: 20 November 2012 Tobacco in Australia: 56 Facts and Issues the provision of stop-smoking services among its military installations, which include counselling and access to pharmacotherapy. Opinions were mixed on tobacco-control strategies for the military, with some response favouring a tobacco-free environment, while others were concerned about the unintended consequences of a complete ban on tobacco in the service.107 Studies of US war veterans conclude that additional effort is required to support smoking cessation in this community of particularly high smoking prevalence.105,106,108 A study of returned servicemen from the Iraq war and the Afghanistan war indicated an association between heavy daily smoking and emotional numbing, suggesting that veterans suffering post-traumatic stress, smoke to overcome trauma.109 Less information is available about current smoking rates among either active service personnel or veterans in Australia. Based on the relative incidence of smoking-related cancers, smoking rates among veterans of the Korean war are believed to be higher than those of the general population.110 Smoking may interact with exposure to other carcinogenic agents during war service, resulting in higher cancer rates in this group. A study of Australian Army Vietnam veterans aimed to assess the relationship between military and war service with mortality and length of life, 36 years after repatriation from the Vietnam War. Their findings indicated that mortality risks among these veterans are linked to regular enlistment, an increased chance of not being in an intimate relationship later in life and increased risk-taking behaviour either during service or higher rates of health-risk behaviours, such as smoking, post-service. They concluded that increased risk of mortality among these veterans is likely to arise from health-risk behaviour such as smoking, inactivity and poor diet, rather than from war service per se or psychiatric disorder.111 9.6.9 Indigenous communities Refer to Chapter 8 for a full discussion on smoking in Australia’s Indigenous communities. 9.6.10 Vulnerable youth While generally they enjoy very good health, there are rising rates of obesity and sexually transmissible infections as well as higher levels of physical inactivity in young Australians aged 15–24 years. Many are using an illicit drug, consuming alcohol at harmful levels and are burdened by mental disorders.3 Prevalence of tobacco smoking in Australians aged 15–24 years was estimated to be 17% in 2007.3,5 Prevalence of asthma among Australian males and females aged 15–24 years was about 11% in 2007–08. It was just under 12% in males aged 10–14 years and about 7% in females of the same age.112 Asthma attacks are more common and more severe in young people exposed to secondhand smoke.113 Disadvantaged parents are much more likely to smoke indoors than more advantaged parents.44, 114-116 Asthma symptoms are more poorly managed and more frequent in children who live in families in more disadvantaged neighbourhoods.117 Indigenous children and children of non-Indigenous lone mothers, people suffering mental disorders, people with substance abuse problems and prisoners must all be at particular risk of harm caused by tobacco use in addition to exposure to secondhand smoke. Spending on tobacco products in low-income families can mean reduced expenditure on recreational activities, education and even food for children in very disadvantaged families.118 Such children are much more likely to lose a parent (and breadwinner) due to illness and premature death caused by smoking. Absence of smoking restrictions at home is associated with increased risk of smoking uptake by children.119,120 Smoking by parents is highly associated with the uptake of smoking and other high-risk behaviours in children.121 Young people from disadvantaged families who are already facing difficult personal circumstances are at particularly high risk of taking up smoking. Concurrent use of alcohol and tobacco use during early adolescence has been found to be associated with risk factors that are predictive of alcohol use and dependence later in life.122 Furthermore, disadvantaged youth exposed to more substance users in their social groups report greater alcohol, Section: 9.6.10 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 57 cigarette and marijuana consumption regardless of whether members of the social group provided tangible or emotional support.123 Mental health problems in young people are strongly associated with engagement in risky behaviours.124 Smoking rates are high among young people in institutional care125 and screening and treatment for smoking is often not addressed in institutional care.126 Depression vulnerability was found to be predictive of smoking among young female college students in the US.127 Among boys admitted to psychiatric inpatient care in Finland, cannabis and hard drug use was associated with past placement in child welfare.83 One international study suggests that smoking by adolescents may limit their subsequent life chances independent of the effects of socio-economic status.128 Anecdotal evidence suggests that smoking status in Australia may be starting to affect employability and to limit choices in housing and in dating129 and, therefore, perhaps also in the establishment of long-term relationships. 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Available from: http://tobaccocontrol.bmj.com/ cgi/content/abstract/17/1/25 Section: 9.6.10 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 63 9.7 Explanations of socio-economic disparities in smoking ‘The relation between SES and smoking patterns is complex involving cumulative and multiple effects across the human life course, possibly extending from one generation to the next.’ Gilman et al 20031 p807 Higher smoking rates among disadvantaged groups are associated with a web of interacting physiological, psychological, social, commercial, economic and cultural factors,2 including: < Section: 9.7 Date of last update: 20 November 2012 Tobacco in Australia: 64 Facts and Issues of more replication or demonstration of inequalities, and call for a much greater focus in research on the ‘black box’ of how to go about reducing them.49, 52-54 Beyond social epidemiology, researchers from many other academic and professional disciplines have also explored physiological, psychological and sociological factors related to social disparities in tobacco use. Figures 9.7.1 and 9.7.2 attempt to sketch out how a variety of physiological, psychological and sociological factors may be working to maintain socio-economic disparities in smoking uptake and smoking cessation. Foetal exposures External cues to use: Parents, siblings Availability –ve Modelling Signi cant adults A ordability Media portrayals (in lm, Promotion Cost Internal cues to use: internet, news coverage, Opportunity Pocket money Impaired emotional regulation magazine photos and Lack of intrinsic rewards advertisements) Access to cigarettes Curiosity, experience Friends Unsupervised time Dependence –ve –ve Past drug experience Resistance to smoking +ve –ve Resources to resist: Alternative rewards Knowledge Understanding of Information through in uences school, media Disturbed families Alienation Coping skills Failure Rejection –ve Less than optimal education Figure 9.7.1 Factors driving socio-economic disparities in smoking uptake External in uences on personal Non-cognitive resources: External barriers to quitting: –ve resources: Emotional regulation Friends smoking Life stress Genetic susceptibility Smoking cues and opportunities Fewer economic resources Past drug experiences Product characteristics Impaired social supports Learned helplessness Promotion –v More limited education e Availability Affordability External aids: Medication Sustained cessation e Coaching +v HP advice to quit Cognitive resources: Social support +ve Knowledge of consequences Alternative rewards Coping skills Information Self-e cacy Understanding of in uences Figure 9.7.2 Factors driving socio-economic disparities in smoking cessation Source: Thank you to Dr Ron Borland for helping to simplify a previous version of these two diagrams. 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Archives of Pediatrics & Adolescent Medicine. 2006;160(9):885-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16953010 36. Soulos G, and Sanders S. Promoting tobacco to the young in the age of advertising bans. N S W Public Health Bulletin. 2004;15(5-6):104-6. Available from: http://www.ncbi.nlm.nih. gov/pubmed/15543244 37. Moolchan ET, Fagan P, Fernander A, Velicer W, Hayward MD, King G, et al. Addressing tobacco-related health disparities. Addiction. 2007;102 (suppl. 2):30–42. Available from: http://cat. inist.fr/?aModele=afficheN&cpsidt=19108854 38. Brunner E, Shipley M, Blane D, and al e. When does cardiovasular risk start? Past and present socioeconomic circumstances and risk factors in adulthood. Journal of Epidemiology and Community Health. 1999;53(12):757–64. Available from: http://jech.bmj.com/cgi/reprint/53/12/757 39. Power C, Graham H, Due P, Hallqvist J, Joung I, Kuh D, et al. The contribution of childhood and adult socioeconomic position to adult obesity and smoking behaviour an international comparison. International Journal of Epidemiology. 2005;34(2):344–55. Available from: http://ije.oxfordjournals.org/cgi/content/full/34/2/335 40. Galobardes B, Lynch J, and Smith DG. Childhood socioeconomic circumstances and cause-specific mortality in adulthood: systematic review and interpretation. Epidemiologic Reviews. 2004;26(1):7–21. Available from: http://epirev.oxfordjournals.org/cgi/content/full/26/1/7 41. Harville E, Boynton-Jarrett R, Power C, and Hypponen E. Childhood hardship, maternal smoking, and birth outcomes: a prospective cohort study. Archives of Pediatrics & Adolescent Medicine. 2010;164(6):533–9. Available from: http://archpedi.ama-assn.org/cgi/content/full/164/6/533 42. Evans G, and Kutcher R. Loosening the link between childhood poverty and adolescent smoking and obesity: the protective effects of social capital. 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Australian and New Zealand Journal of Public Health. 2001;25(2):438–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11688624 51. Fergusson D, Horwood L, Boden J, and Jenkin G. Childhood social disadvantage and smoking in adulthood: results of a 25-year longitudinal study. Addiction. 2007;102(3):475–82. Available from: http://www3.interscience.wiley.com/journal/117967806/abstract 52. Schaap M, and Kunst A. Monitoring of socio-economic inequalities in smoking: learning from the experiences of recent scientific studies. Public Health. 2009;123(3):103–9. Available from: http://www.publichealthjrnl.com/article/PIIS0033350608003077/fulltext 53. Dixon J, and Banwell C. Theory driven research designs for explaining behavioural health risk transitions: the case of smoking. Social Science & Medicine. 2009;68(12):2206–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19394742 54. Greaves L, and Hemsing N. Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure. Drug and Alcohol Dependence. 2009;104(suppl 1.):S121–S30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19520523 Section: 9.7 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 67 9.8 Are current strategies to discourage smoking in Australia inequitable? As described in Section 9.1, smoking rates among those living in the most disadvantaged areas of Australia are double those living in the most advantaged areas. Smoking has declined in all social groups, however the plummeting in smoking prevalence in the highest socio-economic group has not to date been observed in the remaining 80% of the population (refer Section 9.2). It must be remembered that smoking rates have been higher among disadvantaged groups since long before the introduction of tobacco-control policies, and that in the absence of tobacco-control policies, they may well have greatly increased. Whether current tobacco-control strategies are effective in reaching low socio-economic groups has been discussed by several commentators.1-4 Graham comments that the reductions seen in smoking prevalence in developed countries have come about from tobacco-control policy and subsequent cultural ‘shift’, where the desirability and acceptability of smoking has been eroded and smoking is increasingly viewed as socially unacceptable. Much of the gain in driving declines in smoking prevalence is attributable to tobacco-control policies, through such strategies as population-wide messages that depict the harms of smoking, and environmental regulations that limit smoking in public areas. Graham comments that these policies serve to protect public health (for both smokers and for those unwillingly exposed to smoke) and at the same time generate a shift in social norms, whereby smoking and by extension, the smoker, become increasingly stigmatised. Graham notes that although tobacco-control policy has involved a degree of stigma to effect change, smoking is now disproportionally represented in the most disadvantaged parts of populations, where there are marked inequalities in life expectancy, living standards and health outcomes. Graham recommends that tobacco-control policy and research should be conducted with an appreciation of social class and drivers of social inequality and an understanding of how social class operates to ‘produce smoking and smokers as stigmatised’.5 Overseas and local evidence strongly suggest that population strategies such as graphic television advertising of the health effects of smoking and increases in taxes on cigarettes in fact have reduced smoking across all socio-economic groups. International research on the impact of price increases has generally found higher responsiveness to price among lower socio-economic groups6–9 and emerging local evidence echoes these findings.10 Siahpush and colleagues found a strong association between real price increase on cigarettes and declines in smoking prevalence in Australia, particularly so in lower-income groups. One Australian dollar increase in cigarette price was associated with declines of 2.6%, 0.3% and 0.2% in the prevalence of smoking in low, medium and high-income groups, respectively.11 Section 9.10 contains further discussion on tobacco-control strategies and the effect on the disadvantaged. This section examines evidence about the relative impact of population-level tobacco-control strategies on various socio-economic status (SES) groups and provides links to further discussions on social marketing in Chapter 14 and tax in Chapter 13; both of these are key mechanisms in population-wide tobacco-control strategies. 9.8.1 Impact of mass media A meta-analysis of the most rigorous studies since 1980 on the impact of mass media advertising has shown that such campaigns are effective across education levels and different racial groups.12 In the US, low-education women seem to have been particularly responsive to media-based tobacco-control efforts.9 A detailed discussion on the impact of mass media can be found in Chapter 14, Section 14.4. Section: 9.8.1 Date of last update: 20 November 2012 Tobacco in Australia: 68 Facts and Issues 9.8.1.1 Impact of mass media in reducing disparities in smoking-related knowledge In Australia, television advertising has been extremely effective in raising awareness of the health effects of smoking among blue collar and less educated groups. In the mid-1980s in Australia, people with limited formal education and blue collar workers were much more likely than people with post-school qualifications and white collar workers to believe that no illnesses were caused by smoking, and that some illnesses were helped by smoking.13, 14 However, studies monitoring the impact of the Quit Campaign introduced in Victoria in 198515 and the National Tobacco Campaign introduced across Australia in 199716,17,18, 19indicate a steady increase in knowledge among people with all levels of education about the health effects of smoking—such as emphysema, heart disease, stroke and macular disease—which were the subject of television commercials used in the campaigns (see Chapter 14, Sections 14.3.1.2 and 14.4.4 for a detailed discussion on the impact of the National Tobacco Campaign in Australia). Data from wave 5 (2006) of the International Tobacco Control Four Country Survey indicated that more than 90% of people reported having noticed publicity on television on smoking in the last six months, with no differences in level of awareness between groups with various levels of educational attainment.20 Disparities in knowledge about the health effect of smoking still exist, but these are much less pronounced in Australia than they are in the UK, where TV advertising on the health risks of smoking has been less prominent.21 Disparities are also much more pronounced in the case of health conditions that have not been the subject of television commercials. Data from wave 5 of the International Tobacco Control Policy Four Country Survey evaluation study indicated, for instance, that Australians with a university education were only 4% more likely than people who had not finished high school to agree with the proposition that smoking causes stroke.20 However, they were 15% more likely to agree that smoking causes impotence, a topic which, while it had been quite frequently reported in newspapers, has never been the subject of a television commercial or package health warning in Australia (Figure 9.8.1). Data from Wave 8 (2010–11) of the International Tobacco Control Four-Country Survey provides a comparison to the earlier findings of Wave 5 (2006). Although health knowledge appears to have decreased somewhat— particularly so in relation to respondents agreeing that smoking causes impotence—trends by education have remained relatively consistent between survey waves—see Figure 9.8.2. Not nished high school Not nished high school 100 Finished school 100 Finished school 90.6 91.5 90.6 91.5 90 87.7 89.7 Trade quali cation 90 87.7 89.7 Trade quali cation 80 University 80 University 70 73.5 70 73.5 58.0 61.7 61.1 58.0 61.7 61.1 60 60 % 50 % 50 40 40 30 30 20 20 10 10 0 0 Stroke Impotence Stroke Impotence Figure 9.8.1 Figure 9.8.2 Proportion of smokers 18 years and over agreeing that smoking Proportion of smokers 18 years and over agreeing that smoking causes causes stroke (subject of TV advertisement) and impotence (subject stroke and impotence, Australia, 2010–11, by educational attainment of newspaper stories but not TV advertising), Australia, 2006, by Source: Data file provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by educational attainment Partos T, and Borland R. Knowledge Building Team, Cancer Council Victoria. Melbourne. Responses to eighth wave of the International Tobacco Control Four-country Survey, Source: Data file provided to Michelle Scollo of the Tobacco Control Unit, Cancer Council Victoria, smoking causes stroke and impotence, unpublished data, 2012. by Cooper J and Borland R: responses to fifth wave of the International Tobacco Control Four-country Survey, by educational attainment and income adjusted for household size, * Note: University education referred to as ‘some university’ in Wave 8 data. unpublished data, 2008 Section: 9.8.1.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 69 While stroke was a subject of anti-smoking television campaigns in NSW and Victoria in the year 2007, smoking- related impotence has of 2011, not been the subject of a television campaign or featured on cigarette pack warnings. For a timeline of Australian social marketing campaigns see Chapter 14, Section 14.3. 9.8.1.2 Impact of mass media led campaigns across socio-economic groups in Australia See Chapter 14, sections 14.3 and 14.4 for a discussion on the impact of mass media led campaigns across socio- economic groups in Australia. 9.8.2 Differential impact of price increases on low-income groups in Australia Cigarettes in Australia are among the most expensive in the world. Frequent increases in fees and excise and customs duty on tobacco products up until 2001 appear to have had a significant impact on smoking among all socio-economic groups over that time, with a significantly greater effect among those on low incomes. Among people who were still smoking at the end of the first phase of the National Tobacco Campaign in Australia (May 1997 to November 1999), the prevalence of smoking decreased more among blue than white collar groups during the second phase of the campaign (November 1999 to November 2002) when prices of tobacco products increased significantly.22 Smoking declined by 6.1% in blue collar groups and increased by 0.9% in white collar groups. A very detailed analysis of changes in monthly smoking prevalence in response to changes in cigarette prices in each Australian state and territory between February 1991 and December 2006 showed that compared with people on moderate and high incomes, a higher percentage of people on low incomes stopped smoking in response to increases in the price of cigarettes.11 A detailed discussion on the impact of tobacco price increases on low-income groups can be found in Chapter 13, Section 13.11. 9.8.3 Differential impact of campaigns and price increases on disadvantaged children in Australia Socio-economic trends in smoking prevalence among Australian children also appear to reflect overall levels of tobacco-control funding and taxation policy. A study of smoking among children in schools located in suburbs with varying degrees of socio-economic disadvantage in all Australian states and territories between 1987 and 2005 indicated that smoking prevalence decreased in all SES groups.23 However, the level of tobacco-control activity affected the consistency of change across different SES groups, particularly in teenagers aged 12–15 years, the period of peak smoking uptake. As indicated in Table 9.8.1, in the period of low tobacco-control funding and activity in Australia (1992–1996), smoking prevalence increased among students aged 12–15 years, with the greatest increase among low-SES students. In a period of high tobacco-control activity (1997–2005), by contrast, smoking decreased quite sharply and reductions were consistent across SES groups. As indicated in the middle columns of Table 9.8.1, the prevalence of smoking increased very sharply in low-SES teenagers during the period of low tobacco-control activity, whereas there was little change among the higher-SES teenagers. Section: 9.8.3 Date of last update: 20 November 2012 Tobacco in Australia: 70 Facts and Issues Published research on the effect of cigarette price on young Table 9.8.1 people in Australia is somewhat limited; however a study Absolute changes in reported smoking prevalence among of Scottish teens and the relationship between smoking and students aged 12–15 years during high and low periods of the young people’s personal income and parental social class tobacco-control activity, Australia, 1987–1990, 1990–1996 provides further information in this area. West and colleagues’ and 1996–2005, in schools in various socio-economic analysis showed the effect of income on smoking was strongest status quartiles among higher social class youths. Despite the fact that the proportion of weekly income apparently spent on tobacco was greater among lower social class youths, the association of Socio- Absolute change income on smoking was weak or non-existent among lower economic 1990–96 low 1996–2005 24 1987–90 social class youths. status activity high activity quartiles Phase 1 (%) Phase 2 (%) Phase 3 (%) 9.8.4 Monthly smokers Lowest –1 +6 –12 Differential impact of smokefree Second –2 +3 –10 Third 0 +1 –12 policies Highest –1 +1 –13 Evidence about the relative impact of smokefree policies on Current smokers (smoked in past week) disadvantaged compared with advantaged groups is mixed. Thomas and colleagues reported that such policies generally Lowest –1 +5 –11 appeared to result in greater benefits for higher income and Second –2 +2 –9 10 educational groups. It is likely, however, that this finding Third –1 +1 –10 reflects the fact that such policies have been adopted earlier Highest +1 –1 –11 in white collar environments. A study by Dinno and Glantz Committed smokers (smoked on three days in past week) published in 2009 indicated that comprehensive smokefree policies covering workplaces and venues such as bars and clubs, Lowest 0 +2 –7 as well as cigarette price increases, are as likely to discourage Second –1 +2 –6 smoking among low-SES as among high-SES groups25 (see Third 0 0 –7 Chapter 15, Section 15.9.5 for further details). Very few studies Highest –1 0 –7 in Australia have examined the relative impact of restrictions on smoking in workplaces and indoor and outdoor public places. A study in Victoria did find that significantly more persons Source: White, Hayman and Hill 200823 in the lower socio-economic group (measured by educational attainment) reported smoking less after the introduction of smokefree hospitality venues in Victoria compared with those of higher socio-economic status (40% compared with 24%).26 Section: 9.8.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 71 References 1. Baum F. Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants. Global health promotion. 2007;14(2):90–119. Available from: http://ped.sagepub.com/cgi/content/abstract/14/2/90 2. Zhu S, Hebert K, Wong S, Cummins S, and Gamst A. Disparity in smoking prevalence by education: can we reduce it? Global health promotion. 2010;17(suppl. 1):29–39. Available from: http://ped.sagepub.com/content/17/1_suppl/29.full.pdf+html 3. Niederdeppe J, Kuang X, Crock B, and Skelton A. 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Melbourne. Responses to fifth wave of the International Tobacco Control Four-country Survey, by educational attainment and income adjusted for household size, unpublished data (personal communication). Data file provided to Michelle Scollo of the Tobacco Control Unit, 2008. 21. Siahpush M, McNeill A, Hammond D, and Fong GT. Socioeconomic and country variations in knowledge of health risks of tobacco smoking and toxic constituents of smoke: results from the 2002 International Tobacco Control (ITC) Four Country Survey. Tobacco Control. 2006;15(suppl. 3):iii65–70. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii65 22. Scollo M, Younie S, Wakefield M, Freeman J, and Icasiano F. Impact of tobacco tax reforms on tobacco prices and tobacco use in Australia. Tobacco Control. 2003;12(suppl. 2):ii59–66. Available from: http://tc.bmjjournals.com/cgi/content/abstract/12/suppl_2/ii59 23. White VM, Hayman J, and Hill DJ. Can population-based tobacco-control policies change smoking behaviors of adolescents from all socio-economic groups? Findings from Australia: 1987–2005 Cancer Causes and Control. 2008;19(6):631–40. Available from: http://www.springerlink.com/content/x1h33x711616h254/ 24. West P, Sweeting H, and Young R. Smoking in Scottish youths: personal income, parental social class and the cost of smoking. Tobacco Control. 2007;16(5):329–35. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/5/329 25. Dinno A, and Glantz S. Tobacco control policies are egalitarian: a vulnerabilities perspective on clean indoor air laws, cigarette prices, and tobacco use disparities. Social Science and Medicine. 2009;68(8):1439–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19282078 26. McCarthy M, Durkin S, Brennan E, and Germain D. Smokefree hospitality venues in Victoria: public approval, patronage and quitting behaviour, 2004–2007. CBRC Research Paper Series no 32. Melbourne, Australia: Centre for Behavioural Research in Cancer, Cancer Council Victoria, 2008. Available from: http://www.cancervic.org.au/downloads/cbrc_research_papers/ CBRC_res_paper_smokefree_ven32-08.pdf Section: 9.8.4 Date of last update: 20 November 2012 Tobacco in Australia: 72 Facts and Issues 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. 9.9.1 160 142 Quitlines 140 120 102 102 In the US, a national telephone helpline promoted through 100 99 86 television advertising was used more by disadvantaged groups than 80 2, 3 by other population segments. Data on individual-level measures 60 of SES are not collected on callers to the Australian national 40 Quitline, but analysis of caller postcodes provides some indication 20 of trends within different socio-economic groups, as do population 0 surveys that ask smokers about their use of services. 1st 2nd 3rd 4th 5th (lowest) (highest) 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 Figure 9.9.1 60% more likely to call the Quitline than people in less affluent Average number of calls per month to the Quitline per 100 000 suburbs.4 This finding is consistent with the greater health and smokers, Victoria, Australia, 2001–04, by quintile of disadvantage 4 consumer literacy of people with higher levels of education. Source: Siahpush, Wakefield, Spittal and Durkin 2007 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- 8 7.6 7.0 economic quintiles. 7 6.0 The study by Siahpush and colleagues also showed that increasing 6 5.0 5.2 the level of TV advertising was at least as effective in prompting 5 4.8 additional calls to the Quitline in lower, compared with higher, % 4 SES groups. A high level of target audience rating points (TARPs) 3 resulted in a 273% increase in calls in the lowest quintile and a 2 250% increase in the highest SES quintile when compared with 1 periods without any TV advertising.4 0 Less than $15 000 to $25 000 to $35 000 to Over Not Data combined from waves six, seven and eight of the $15 000 $24 900 $34 999 $49 999 $50 000 disclosed International Tobacco Control (ITC) Four-country Survey (years 2008 to 2010, during which time spending on media campaigns Figure 9.9.2 was substantially higher than the previous six years) suggests Proportion of smokers who received advice or material from the that among Australians still smoking at the time they were last Quitline in the past year, Australia, combined waves six, seven, eight surveyed, those in the lowest income group were no less likely and from ITC 4-country survey, 2007–10, by annual household income may have been slightly more likely than other smokers to have ever Source: Data file of responses (combined) to sixth, seventh and eighth wave of the International called the Quitline (Figure 9.9.2). 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 Section: 9.9.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 73 9.9.2 Disparities in use of treatments for tobacco dependence 9.9.2.1 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). 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 40 35.1 use stop smoking medication to aid a quit attempt. 35 32.9 30 30.0 Figure 9.9.4 also presents wave eight data (2010) of the 26.7 International Tobacco Control Four-country Survey on 25 23.2 all smokers, not just those that made a quit attempt since %20 last being surveyed. It shows that low income smokers 15 were no less likely to make a quit attempt than the highest 10 income smokers. Like Figure 9.9.3, smokers in the lower 5 income brackets were actually more likely than those of the 0 highest income bracket to use a prescription stop-smoking Less than $30 000 to $45 000 to $60 000 Not medication aid in their most recent attempt. There was quite $30 000 $44 999 $59 999 and more disclosed a difference in particular between the high income groups using a prescription stop-smoking medication in their Figure 9.9.3 quit attempt (11.6%), compared with those in the lowest Proportion of Australian smokers using prescription stop-smoking income group (18.4%). It is worth noting that these figures medications on their last quit attempt, among those who made quit represent use of prescriptions medications only in the last attempts, 2010, by annual household income quit attempt—so those who did not answer ‘yes’ to using a Source: Data file of responses to eighth wave of the International Tobacco Control Four-country prescription medication in their most recent quit attempt Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, Cancer Council Victoria, 2012 Section: 9.9.2.1 Date of last update: 20 November 2012 Tobacco in Australia: 74 Facts and Issues may still have used prescription medication in previous 60 Less than $30,000 quit attempts during the survey period (July 2010 to 53.8 $30,000 to $44,999 50.8 December 2010), or the smoker may have been prescribed 50 47.3 48.4 $45,000 to $59,999 45.3 stop-smoking medication but had not used it, or made a $60,000 and more 40 quit attempt. Therefore it is possible these figures may very Not disclosed slightly underestimate prescription medication use. % 30 Bupropion (known as ‘Zyban’) has been listed on Australia’s 20 18.4 14.7 14.4 14.8 Pharmaceutical Benefits Scheme (PBS) since February 11.6 2001 and varenicline (under the trade name ‘Champix’) 10 since January 2008. Before 2011 in Australia, NRT was not 0 Used a prescription stop-smoking Did not make a quit attempt subject to subsidies under the PBS), with the exception medication in most recent quit attempt 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 Figure 9.9.4 under the Repatriation Benefits Scheme since 1994—see Proportion of Australian smokers using prescription stop-smoking Section 7.16.1.) medications on their last quit attempt and smokers who did not make a quit attempt, 2010, by annual household income However from 1 February 2011, the listing for subsidised Source: Data file of responses to eighth wave of the International Tobacco Control Four-country NRT patches on Australia’s PBS was extended to include Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by all Australians (both general and those eligible for T Partos and R Borland, Cancer Council Victoria, 2012 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. 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 Figure 9.9.5 prescribed NRT were concession patients. Number of prescriptions filled for anti-smoking medications under the Pharmaceutical Benefits Scheme, Australia, January 2008 to December 2011: concession prescriptions versus ordinary prescriptions 9.9.2.2 Source: Medicare Australia 201111 Note: Includes prescriptions for bupropion (Zyban) and varenicline (Champix) from January Disparities in compliance with treatment 2008 and nicotine replacement therapy from January 2011 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 Section: 9.9.2.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 75 9.9.3 Disparities in provision of quit smoking advice and referral by general practitioners Data from the seventh wave of the International Tobacco 57 Control Four-country Survey (between October 2008 and 56.1 56 March 2009) showed that smokers of lower educational 55.3 attainment were more likely than any other group to report 55 being advised to quit smoking by their doctor. There was 54 53.6 a slight increase from 2006 among smokers who had % 53 completed schooling, obtained a trade qualification or 52 51.5 completed some university reporting being advised to quit 51 (up from 51%, 52% and 48% respectively). 50 There is little evidence of inequities in access to 49 Not nished Finished Trade Some pharmacotherapies and services for treatment of tobacco high school high school quali cation University* dependence in Australia. However, given the higher level of dependency and less than optimal use of available services Figure 9.9.6 and treatments, there is still scope for improving general Proportion of smokers who could recall having been advised to quit by practitioner identification of smokers, advice to quit, and their doctor, Australia, 2008–09, by level of educational attainment use of NRT and the Quitline by lower-SES smokers. 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 Section: 9.9.3 Date of last update: 20 November 2012 Tobacco in Australia: 76 Facts and Issues References 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 Section: 9.9.3 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 77 9.10 Further initiatives to reduce tobacco-related disparities in Australia In Australia, tobacco control policy units, health promotion foundations and Quit campaigns are all greatly concerned about socio-economic disparities in smoking. Addressing social disadvantage associated with smoking is an objective of Australia’s National Tobacco Campaign that operates under the auspices of the Australian National Preventive Health Agency (ANPHA). The National Tobacco Campaign aims to reach high-need and highly-disadvantaged groups through a multi-tiered targeted social marketing campaign.1 Reducing disparities and disadvantage is also subject of state-based tobacco control initiatives, including the Tackling Tobacco Program operating in NSW2 and the Tobacco and Mental Health project in South Australia. 3 The Victorian Health Promotion Foundation (VicHealth) has established a program to reduce health inequalities among Victorians though a focus within its program areas on determinants such as social connection or race-based discrimination, or risk factors including smoking and alcohol consumption.4 Reducing smoking among disadvantaged groups is also a key priority for Quit Victoria.5 The following presents what is known about 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 systematic review of research on the impact of population-wide tobacco control policies published in 2008 found no evidence of a greater impact on higher socio-economic groups for smoking restrictions in schools or workplaces, restrictions on sales to minors, bans of advertising of tobacco products, health warnings or multi-faced interventions. The review also found significant evidence of greater effectiveness of price increases among those with lower incomes and manual occupations.6 Main and colleagues’ review of 19 systematic reviews of population- level tobacco control interventions that reported on at least one socio-demographic characteristic found that few studies attempted to analyse effects by SES—something which they felt should be explicitly addressed in future reviews and in research of intervention efficacy. Overall there was little to suggest lower levels of effectiveness among disadvantaged groups. They concluded that there was preliminary evidence to suggest that increasing the unit price of tobacco may reduce smoking related health inequalities.7 An analysis of nation-wide tobacco control strategies in 18 European countries found that countries with the most comprehensive policies had the highest proportion of ex-smokers. National scores on a scale measuring the comprehensiveness of national tobacco control policies were positively associated with quit ratios in all age–sex groups. High and low educated smokers benefited roughly equally from nation-wide tobacco control strategies.8 In addition to these three systematic reviews of the effectiveness of population-level tobacco control policies across socio-economic groups above,6, 8 two papers have assessed available research and specified which strategies are most likely to reduce disparities between advantaged and disadvantaged groups. One of these identified advertising bans, smoking bans in workplaces, removing barriers to smoking cessation therapies, and increasing the cost of cigarettes as having the potential to reduce socio-economic inequalities in smoking in western European countries.9 The other review concluded that there was good evidence that tobacco taxation, thematically appropriate mass media campaigns and appropriate smoking cessation support services could reduce tobacco-related disparities in New Zealand.10 The potential for further progress with each of these strategies in Australia is discussed below. Section: 9.10.1 Date of last update: 20 November 2012 Tobacco in Australia: 78 Facts and Issues 9.10.1.1 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. Smoking prevalence in the least advantaged households declined significantly in Australia between 2007 and 2010, as reported in the National Drug Strategy Household Surveys11, 12 after several periods of little change in this part of the population.11, 13 The most commonly reported reasons for changes in smoking behaviour among smokers in 2010 were because smoking was affecting their health, and because it was costing too much. 12 Price affects tobacco use more substantially than any other strategy, and it seems that this is particularly so among lower socio-economic groups. Australian research reports that tax increases in the past have had a substantial impact on smoking in low socio-economic groups.14-16 Several substantial reviews have examined studies assessing the effect of price increases on smoking and tobacco consumption among disadvantaged groups.6, 17-19 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 with 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.20 For a further detailed discussion on tobacco price and impacts on low socio-economic groups, see Chapter 13, Section 13.11. 9.10.1.2 Smokefree policies Policy interventions such as workplace smoking bans affect not only individuals21 but also people in the family and friendship groups of those affected. Smokefree workplace policies reduce the amount of tobacco smoked, reduce exposure to secondhand smoke and reduce the chances of a quitter relapsing. There is also evidence that they increase quitting.19 Drawing on social diffusion theory and a wealth of data collected since 1970 from the landmark Framingham study, a major US paper published in the New England Journal of Medicine in 2007 described how social behaviours such as weight loss and quitting can be spread person to person like a viral infection.22 A further study published in 2008 showed that ever smokers were about 70% more likely to have quit over the previous 30 years if their spouse had quit, about 25% more likely if a sibling had quit, 36% more likely if a friend had quit and 34% more likely if a co-worker had quit.23 A study by the John F Kennedy School of Government at Harvard University went on to use network analysis to demonstrate how workplace smoking bans could contribute to declining prevalence of smoking.24 All Australian states and territories have now implemented bans on smoking in enclosed workplaces, including in hospitality venues—see Chapter 15 for further detail on smokefree policies in Australia. The extension of smokefree policies from restaurants to pubs in Victoria was reported to have a more profound impact on Victorian smokers in the lower socio-economic group (measured by educational attainment), with 40% reporting smoking less after the introduction of the ban, compared with 24% in the higher socio-economic group.25 Many Australian states and territories have in more recent times, extended smokefree policies to cars carrying children, and to outdoor areas, such as playgrounds and outdoor dining areas. The implementation of smokefree Section: 9.10.1.2 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 79 cars carrying children has the potential to reduce disparities in health outcomes, by reducing secondhand smoke exposure in children of parents that smoke. Diffusion theory would predict that the social multiplier effects of smokefree policies will be much greater when they apply to large geographic areas and to many different sorts of venues. The effects of such policies on people in disadvantaged groups should be greater where such policies extend to more blue collar work environments and to a greater range of sporting, hospitality and retail venues.26 Extending smokefree policies to private residences has been generally thought to be beyond the bounds of regulation. Winickoff examines this notion, and points to the potential of smoking bans in high density public housing to reduce secondhand smoke exposure among the disadvantaged.27 9.10.1.3 Pictorial health warnings Pictorial health warnings introduced in Australia in 2006 may have been more effective in gaining attention among less educated smokers than among smokers with a university education. Figure 9.10.1 shows the frequency with which smokers of various levels of educational attainment noticed the pictorial health warnings in the first few months after introduction of the warnings in 2006. The proportion of smokers who looked at 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. While generally people with higher levels of education take a more planned approach to quitting, it could be that these graphic warnings are somewhat more effective among lower than higher SES groups in prompting action. Data from Wave 8 (July 2010–May 2011) of the International Tobacco Control (ITC) Four-country Survey allows comparison with ITC data from 2006—see Figure 9.10.2 The 2010 data shows moderate differences between education attainment level and reading or looking at warning labels on cigarette packets. Those who had some university education were still slightly less likely than those of lower educational attainment or qualification to report reading or looking at warning labels often or very often. 45 43 70 42 63.7 40 40 40 39 59.5 40 38 60 56.9 58.0 Not nished high school 35 Finished school 32 50 30 Trade quali cation University 25 40 % Not nished high school % 20 Finished school 30 15 Trade quali cation 21.9 22.3 20 19.2 18.6 10 University 5 10 0 0 Total rarely or never Total often or very often Rarely or never Often or very often Figure 9.10.1 Figure 9.10.2 Percentage of smokers rarely and frequently reading new pictorial Percentage of smokers reporting reading or looking closely at the health warnings on cigarette packets, smokers 18 years and over, health warnings on cigarette packets in the past month, smokers Australia 2006, by level of educational attainment 18 years and over, Australia, July 2010–May 2011, by educational Source: Data file of responses to the fifth wave of the International Tobacco Control Four-country attainment Survey, by educational attainment and income adjusted for household size, provided to Source: Data file of responses eighth wave of the International Tobacco Control Four-country Michelle Scollo of the Tobacco Control Unit, Cancer Council Victoria, by J Cooper and R Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by Borland Cancer Council Victoria, 2008. T Partos and R Borland, Cancer Council Victoria, 2012. Section: 9.10.1.3 Date of last update: 20 November 2012 Tobacco in Australia: 80 Facts and Issues Research conducted in the United States reports a particular impact of pictorial health warnings among smokers of lower socio-economic status. The research found that when comparing text-only warnings with pictorial warnings, participants rated pictorial warnings as more ‘personally relevant’ and ‘effective’. Smokers of low health literacy more notably rated pictorial health warnings as ‘credible’ compared to text based warnings, yet there was no difference between ratings of credibility of pictorial and text health warnings among smokers of high health literacy. In addition, graphic pictorial health warnings (e.g. image of fatal lung disease) were rated significantly more ‘credible’, ‘effective’ and ‘personally relevant’ among participants compared with pictorial warnings displaying symbolic imagery (e.g. tombstones representing death) and human suffering (e.g. image of adult female crying). Interactions between the type of pictorial warning and both race and health literacy were also significant, in that, pictorial warning labels with graphic images produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery (i.e. symbolic imagery) produced greater differences. This suggests that graphic pictorial warning labels are most likely to have the broadest effect; eliciting the greatest and most consistent impact across all sub-populations of smokers regardless of race, or level of health literacy.28 A new Standard consisting of two sets of seven pictorial health warnings apiece will commence rotation on tobacco products in Australia leading up to 1 December 2012i, to correspond with the introduction of plain packaging. The new Standard for pictorial health warnings features some new, as well as existing images.29 The size of the pictorial warning has also been increased to cover at least 75%of the front surface of most tobacco product packaging. The Standard maintains the size of 90% of the back surface for cigarette packaging, but requires an increase to 75% of the back surface of most other tobacco products—see Chapter 12, Attachment 1, Section A1.1 for further details. The data presented above suggest that new warnings required under the 2011 Standard are likely to be at least as effective with low as with high-SES groups. 9.10.1.4 Under-the-counter sales of cigarettes With a greater density of retail outlets selling tobacco in disadvantaged areas,30, 31 moves to limit the number tobacco retailers in disadvantaged neighbourhoods and/or prohibit display of cigarettes in retail areas may well have a greater impact in lower SES children and quitters at risk of relapse.ii All Australian states and territories have now banned displays at point-of-sale, Chapter 15 provides more detail on point-of-sale display bans. 9.10.1.5 More effective use of mass media Researchers and managers working on the development of Quit Campaigns in Australia have gone to considerable lengths to target media placement (both in terms of timing and program and program type) and to pre-test advertisements among low-SES groups to ensure that they are attended to by people of lower socio-economic status.33-38 Increasing interest among researchers about the differential effects of advertising style and content39-41 and the differential effects of mass media advertising among different socio-economic groups can also provide crucial guidance on advertising content.40, 42 Research in Wisconsin, for instance,43 shows that advertisements promoting the benefits of quitting and the availability of smoking cessation services are more effective in stimulating action i Either pictorial health warnings from Australia’s old standard (Trade Practices (Consumer Product Information Standards) (Tobacco) Regulations 2004) or the new pictorial warnings from the latest Standard (Competition and Consumer (Tobacco) Information Standard, 2011) are permitted to appear on tobacco product packaging up until 30 November 2012. From 1 December 2012, only the pictorial health warnings from the new standard are permitted to be displayed on tobacco product packaging. See: http://www.yourhealth.gov.au/internet/yourhealth/ publishing.nsf/Content/tobacco-label-images ii While numbers were not large enough to readily detect differences, an Australian study examining impulse purchases following exposure to point-of-sale displays found that smokers in the most disadvantage SES group may have been the most vulnerable.33 Section: 9.10.1.5 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 81 in higher SES groups. Promotion of cessation services through television might seem like an attractive idea for increasing use of services by low income groups, but may in fact result in further disparities in smoking as those in more advantaged areas would be more likely to respond. Investigators believe that emotional narrative communication may be a better method for low-SES groups because it does not rely on explicit arguments or information (which require assessment of the merits of the message, and acceptance of the argument/message).44-46 Durkin and colleagues reported that greater exposure to advertisements containing highly emotional elements or personal stories hold promise for quitting activity in low and mid socio- economic groups.47 Theorists48 have proposed that narrative messages (messages embedded in the lessons of personal stories) may enhance impact and persuasion through minimising smokers’ ability and motivation to counter-argue against a specific argument or message. Emotionally arousing stories are also more likely to be discussed with others,49, 50 and once shared, are more likely to survive and be reproduced.51 Therefore, messages that are personally relevant and emotionally engaging are more likely to increase perceptions of susceptibility to health risks and be passed on to others through interpersonal communication. Narratives are more likely to trigger self-relevant emotional responses, because the viewer is ‘transported’ or absorbed into the emotional experience of characters with whom they identify.52, 53 The use of stories in public health communication has previously been found to be very effective through education‒entertainment54 as well as in anti-smoking advertising.40 Victorian research has shown greater increases in calls to the Quitline from low-SES groups were associated with higher emotion narrative advertisements on air compared with other types of anti-smoking advertisements on air.55 9.10.1.7 Harm reduction: a strategy of benefit for disadvantaged groups? Disadvantaged groups tend to smoke more cigarettes each day and be more dependent on tobacco-delivered nicotine. High rates of mental health problems may also reduce the capacity of many disadvantaged smokers to quit smoking completely. For this reason several commentators have called for consideration of strategies to reduce harm among smokers who are unable to quit and who remain dependent on nicotine. This might include encouraging individual smokers who have repeatedly failed to quit to switch to Swedish-style oral tobacco (snus) which poses less risk to the individual user and creates none of the problems of secondhand smoke—see Chapter 12, Attachment 3.56 More controversially, other commentators have called for the introduction of a regulatory framework that could helps shift the market away from smoked tobacco towards potentially less harmful products including snus and pharmaceutical-grade nicotine.10, 57-60 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. Meta-analyses included in US guidelines for clinical practice show that Quitlines can improve a person’s odds of quitting by about 60% (increasing abstinence rates from 8.5% to 12.7%). Compared with placebo medication, using nicotine replacement therapy, bupropion or varenicline can almost double a person’s chances of success (increasing abstinence rates from about 14% to about 25%). If a person both uses medication and gets coaching from the Quitline they increase their odds still further. Adding the Quitline to medication increases the odds of quitting by 30% (increasing abstinence from 23% to 28%). Adding medication to the Quitline increases chances by about 70% (increasing abstinence rates from 14.6% to 22%).61, 62While many studies of cessation interventions report results stratified by socio-economic group, unfortunately reviews and meta-analyses of such studies (such as those published as part of the Cochrane Collaboration)63 rarely report on efficacy or effectiveness by socio-economic status.64 A systematic review of studies that addressed smoking cessation and improving access to smoking Section: 9.10.2 Date of last update: 20 November 2012 Tobacco in Australia: 82 Facts and Issues cessation services among disadvantaged groups reported that although many studies collected socio-economic information, only few analysed its association with the results. However, the review did find some evidence from the studies of effectiveness of particular interventions in increasing quitting behaviour in disadvantaged groups. This is discussed further in the next section9.10.2.1 (refer Murray and colleagues)65 For a discussion on financial incentives and cessation, seeChapter 7, Section 7.17 9.10.2.1 Face-to-face counselling services? The UK is the only developed country with a national program for the treatment of tobacco dependence, with face-to-face stop-smoking services established first in the most deprived areas of the National Health Service. These are known as Health Action Zones, and have been rolled out to all primary trusts in the country. While services attempt to target disadvantaged groups within each trust by encouraging action by health professionals in more deprived areas, the cost-effectiveness of this labour-intensive approach to smoking cessation has been hotly contested.66-70 Supporters of these services point to data that a greater percentage of people from the most, compared with the least disadvantaged areas, are accessing the services. They argue that although a smaller percentage of people enrolling in clinics in disadvantage areas compared with more affluent areas set quit dates, the total percentage of people attempting to quit has been almost five times higher per capita in the most disadvantaged compared with the most affluent areas.71 Critics point out that the percentage of the smokers accessing the service is extremely small. Because the number of smokers in more advantaged areas is smaller and the percentage who succeed in quitting is higher, overall the impact on low income smokers is probably much more modest in reducing inequalities than might be suggested by the absolute rates of quitting per capita.68 If more high- than low-SES smokers in each area are accessing the services and succeeding in quitting, then these services could even be increasing inequalities.72 In 2010 the UK Government outlined improvements for the NHS services.73 A systematic review conducted to examine the effectiveness NHS stop-smoking services found some preliminary evidence that NHS services were making a modest contribution to reducing inequalities in health through their support of larger proportions of disadvantaged smokers compared with their more advantaged counterparts. The authors noted, however, that additional research was needed to determine the most effective model of treatment, given that the review suggested group treatment may be more effective than one-on-one treatment. They also recommend further specific analysis of demographic characteristics and the differential impacts/efficacy of interventions among sub-groups, to provide a better picture of the most effective treatment model.74 Murray and colleagues echoed the findings of the research above by Bauld and colleagues pointing to evidence that NHS stop-smoking services are making gains in reaching smokers living in deprived neighbourhoods. Primary care does provide the opportunity to target smokers for cessation interventions, but further research is needed to determine efficacy of this approach among disadvantaged smokers and for quit rates overall.65 Bauld et al note that although support provided by community contacts such as pharmacists may not be as effective as intensive interventions in primary settings, these community-based providers may be in a better position to reach disadvantaged smokers not interested in attending group intervention sessions.74 With much lower density of housing than is common in the UK, face-to-face services are unlikely to be feasible in Australia. Section: 9.10.2.1 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 83 9.10.3 Developing targeted services and approaches for smokers where these are needed A number of groups in Australia have needs that are unlikely to be adequately met by mainstream initiatives to encourage and support smokers to quit. As indicated through this chapter, initiatives targeting highly disadvantaged groups are in place in various jurisdictions and sectors in Australia, but these are not uniform across the country. Extending all services nation-wide could further assist in the reduction of smoking in highly disadvantaged groups. The ‘Tackling Tobacco’i 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’. It reported clients of these non-government social and community 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.75 9.10.4 Promoting educational achievement, mental health and social connectedness To eliminate SES disparities in tobacco use will require more than increasing quit attempts in disadvantaged groups. Given the difficulties facing those who have established dependence on tobacco-delivered nicotine, and given that most of the current disparities in tobacco use can be attributed to differential uptake rather than differential rates of cessation, we need to do more to prevent uptake among children, particularly in disadvantaged families. Price increases and social marketing have considerable impact on children from disadvantaged backgrounds. Youth and young adults are also sensitive to price increases in tobacco. 17 It may also be worth trying to influence disadvantaged children through appeals to their parents, siblings and influential peers.76 Appreciation of population social conditions when developing health policy 77,78 and improvements in the social conditions which encourage uptake and continuation of smoking can help advance reductions in uptake of smoking among disadvantaged groups. While dozens of social problems can be associated with high rates of smoking, it is evident that many of these problems stem from and could be mitigated by the prevention of educational failure in children. Young people who do well at school are more likely to understand information about health risks and are more likely to feel connected to school and to feel hopeful about their future. If they succeed in further education and get a good job, they are much less likely to end up in stressful personal circumstances, or to be part of social groups where lots of people smoke. As Hilary Graham and her colleagues have demonstrated educational trajectories (as measured by age of leaving education and educational qualifications) are associated with smoking, with uptake in adolescence as well as current smoking, heavy smoking and quitting in adulthood. Education eliminates the effect of childhood circumstances on these dimensions of smoking status, suggesting that childhood conditions exert their influence through education. Education in turn determines adult socioeconomic position, with poor adult circumstances adding further to the risk of smoking in adulthood and reducing the odds of quitting.79pii8 i The ‘Tackling Tobacco’ program has also been undertaken by Quit SA (South Australia) Section: 9.10.4 Date of last update: 20 November 2012 Tobacco in Australia: 84 Facts and Issues Preventing educational failure is partly about the science of literacy and numeracy, but it’s also about helping schools to work more effectively. Readiness for school, children’s mental health and connectedness with school and community are also important and could help to prevent development of mental health problems and a range of other social problems, all of which are highly correlated with smoking uptake.80, 81 Findings of American research on the association between social cohesion and lower smoking rates,82 and the relationship between social cohesion and self-reported health status83, 84 suggests that improvements in social capital could also help to reduce smoking uptake. European research suggests that policies to reduce the ugliness and disorder of the most disadvantaged neighbourhoods and provide opportunities for young people to participate in activities that build a sense of community may reduce risk-taking behavior including smoking.85, 86. Given the crucial contribution of smoking to the perpetuation of social disadvantage, investment in measures to accelerate the decline of smoking among the less advantaged sections of the population is a public policy likely to yield substantial social as well as financial returns. Acknowledgements Thank you to Dr Ron Borland and his colleagues Jae Cooper and Timea Partos for provision of extensive data from the International Tobacco Control Policy Evaluation study, and for many discussions over the years about this topic the authors. Thank you also to Dr Borland and to the following people for helpful comments on an earlier draft of this chapter: Kylie Lindorff, Dr Sarah Durkin, Dr Vicki White and Dr Melanie Wakefield from Cancer Council Victoria, and to Professor Simon Chapman, University of Sydney. Thank you to Professor Wayne Hall and Dr Coral Gartner from the University of Queensland for their extremely helpful advice and encouragement, and for provision of unpublished analyses from the National Drug Strategy Household Survey. Section: 9.10.4 Date of last update: 20 November 2012 Chapter 9: Smoking and social disadvantage 85 Proposed interventions Social policies Family support, early childhood, education Greater engagement with school and community Reduced alienation system and school interventions to prevent Increased capacity to understand probability and causation Increased salience Reduced alienation educational failure Improved health and consumer literacy Increased quit attempts of Population-wide tobacco control strategies tobacco products, particularly for those on low incomes Increase tax on cigarettes with measures to Higher average cigarettes prices prevent excise evasion Media releases to promote research on new Increased salience of Increased salience popular media more limited education Increase spending and narrative strength of Increased salience anti-smoking education Reduced opportunities to smoke Extend smokefree policies to cars, crowded Reduced opportunities Less smoking by parents, in public, in cars and at home for low income adults and children outdoor venues, outside doorways Reduced modelling Increase size and frequency of change of More attention to pack warnings Increased salience pictorial health warnings Fewer prompts to purchase and to smoke Under the counter sale of cigarettes Fewer visual cues in retail environment Fewer prompts Reduction of smoking by exciting characters in movies Less glamour Less glamour associated smoking with smoking Reduced modelling of cigarette Extra promotion in disadvantaged areas smoking and increased modelling of Increased use of Quitline and courses and tobacco through outdoor advertising, direct marketing Increased quit attempts quitting for low income children treatments in low-SES areas through health professionals and incentives Subsidy of NRT Extra use of NRT and Quitline by disadvantaged Greater quitting success Increase in the numbers of smokers in low income areas attempting to quit Education and support to increase quality Improved compliance Greater quitting success of use Increased quit attempts Greater success in quitting in Development of improved medicines Greater use, compliance and word of mouth promotion disadvantaged groups, including those Greater quitting success who are genetically prone to addiction Figure 9.10.3 Interventions that could balance the factors promoting SES differentials in tobacco use Section: 9.10.4 Date of last update: 20 November 2012 Tobacco in Australia: 86 Facts and Issues References 1. 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