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Addressing the Social Determinants of Inequities in Tobacco Use

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Addressing the Social Determinants of Inequities in Tobacco Use Evidence review: Addressing the social determinants of inequities in tobacco use Kate Purcell vichealth.vic.gov.au 15 Title VicHealth 15 z Victorian Health Promotion Foundation PO Box 154 Carlton South Victoria 3053 Australia T +61 3 9667 1333 F +61 3 9667 1375 [email protected] vichealth.vic.gov.au twitter.com/vichealth facebook.com/vichealth © VicHealth 2015 September 2015 P-EQ-269 VicHealth acknowledges the support of the Victorian Government. Addressing the social determinants of inequities in tobacco use Kate Purcell Purcell Consulting September 2015 Contents Part One: Background ......................................................................................................................... 4 1.1 Introduction .................................................................................................................................. 4 1.2 Purpose of this report ................................................................................................................... 5 1.3 Methodology ................................................................................................................................. 6 Part Two: Prevalence and social distribution of tobacco use ............................................................. 7 2.1 Overview ....................................................................................................................................... 7 2.2 Prevalence of smoking by socioeconomic status and education ................................................. 8 2.3 Aboriginal people .......................................................................................................................... 8 2.4 Children ......................................................................................................................................... 8 2.5 Prisoners ....................................................................................................................................... 9 2.6 People with mental illness ............................................................................................................ 9 2.7 Culturally and linguistically diverse communities ......................................................................... 9 2.8 Disparities in exposure to second-hand smoke .......................................................................... 10 2.9 Smoking in pregnancy ................................................................................................................. 11 2.10 The changing equity gap for tobacco-related inequities in Victoria ......................................... 12 Part Three: The social determinants of inequities in tobacco use ................................................... 14 3.1 Social disadvantage and smoking ............................................................................................... 14 3.2 Socioeconomic, political and cultural factors influencing inequities in smoking ....................... 15 3.3 Daily living conditions ................................................................................................................. 17 3.4 Individual health-related factors................................................................................................. 21 Part Four: What can be done to address the social determinants of inequities in tobacco use? .... 26 4.1 Influencing the socioeconomic, political and cultural context – what works? ........................... 26 4.2 Influencing daily living conditions – what works? ...................................................................... 35 4.3 Influencing Individual health-related factors – what works? ..................................................... 45 Part Five: Conclusions and recommendations for future action ...................................................... 48 5.1 Influencing the socioeconomic, political and cultural context ................................................... 49 5.2 Influencing daily living conditions ............................................................................................... 50 5.3 Influencing Individual health-related factors .............................................................................. 52 5.4 Interventions across the life course ............................................................................................ 52 5.5 Prompts for planning .................................................................................................................. 54 5.6 Addressing evidence gaps ........................................................................................................... 56 References ........................................................................................................................................ 57 Figures Figure 1: Fair Foundations: The VicHealth framework for health equity Figure 2: An incremental approach to reducing inequities Figure 3: Interventions to reduce tobacco-related inequities by life stage Table 1: Estimates of smoking rates in different population groups in Australia Table 2: Summary of effective interventions for young women and pregnant smokers Table 3: Summary of the evidence regarding cessation interventions for disadvantaged groups Part One: Background 1.1 Introduction VicHealth released Fair foundations: The VicHealth framework for health equity (hereafter called the Framework) in October 2013 as a planning tool to inform equity-focused health promotion policy and practice in Victoria, Australia. Eight evidence reviews have been commissioned to support the use of the Framework in relation to healthy eating, tobacco, alcohol, physical activity and mental wellbeing. The focus of this report is on tobacco use. The Framework developed by VicHealth is consistent with the approach developed by the World Health Organization (WHO) Commission on Social Determinants of Health [1]. The social determinants of health are the social conditions in which people are born, grow, live, work, play and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are generally responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries [1]. The social determinants of health inequities refer to the conditions and the social processes that distribute them unequally in society. Tobacco smoking is the leading preventable cause of death and disease in Victoria, costing 4000 lives and $5 billion every year [2]. Considerable progress has been made in reducing smoking rates in the community over the past four decades. The prevalence of regular smoking (daily or weekly) among adults in Victoria has fallen from 21.2% in 1998 to 14.4% in 2011 [3]. However, there has been less success in reducing socioeconomic inequities in smoking. As with most other high-risk behaviours, the prevalence of smoking and associated disease is significantly higher among disadvantaged groups, including low socioeconomic groups [3, 4], Aboriginal people [5, 6], people with mental illness [7], prisoners [8] and homeless people [9]. Another marker of inequity is a clear social gradient for smoking and tobacco-related disease where smoking rates are lower in the most advantaged quartile than in the second quartile, and increase with each quartile of disadvantage [10]. There is clear evidence that there is a social gradient for tobacco use and related illness in Victoria [3]. While there is strong evidence about what works in reducing tobacco use, there is less evidence about the most effective approaches to reduce inequities in tobacco. However, the evidence base has increased over the past decade. The Framework has been developed as a tool to inform and guide efforts to improve health equity in Victoria. The Framework identifies three layers of influence and entry points for action in relation to the social determinants of health inequities. These three layers of influence are socioeconomic, political and cultural context; daily living conditions; and individual health-related knowledge, attitudes and behaviours [11]. Determinants of inequities in tobacco use 4 Figure 1: Fair Foundations: The VicHealth framework for health equity 1.2 Purpose of this report This report provides an overview of the current evidence base about the social determinants of inequities in tobacco smoking and tobacco-related health outcomes, and highlights promising approaches for promoting equitable reductions in tobacco smoking and tobacco-related health outcomes in relation to each of levels of the Framework. It is intended to provide practical, evidence-informed recommendations for promoting equity in relation to tobacco use in Victoria and across Australia. Specifically it aims to: 1. Synthesise current Australian and international evidence describing the social determinants of inequities in relation to tobacco use; 2. Summarise the scope, nature and quality of the evidence base for promoting equity within tobacco control efforts; Determinants of inequities in tobacco use 5 3. Identify promising strategies which could feasibly be implemented in Victoria, and across Australia, at each level of the Framework and identify key policy and implementation considerations; and 4. Identify key gaps in the evidence base and make recommendations for future research priorities in relation to tobacco use and inequity. 1.3 Methodology A rapid review of the
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