Smoking rates in Victoria are at an historic low, according to research released last week by Cancer Council Victoria, which found that 14.4 per cent of Victorians were regular smokers in 2011 compared with 21.2 per cent in 1998.
But in the article below, University of Newcastle researchers Associate Professor Billie Bonevski and Professor Amanda Baker argue that smoking rates are still too high among many disadvantaged groups, and that social change and public health measures are needed.
For those with an interest in equity and tobacco control, they recommend a special issue of the international addictions journal Drug and Alcohol Review.
Smoking is a social justice issue
Billie Bonevski and Amanda Baker write:
In 1998 the public obtained the right to access internal tobacco industry documents, which blew the lid on the industry’s secrets.
We learnt that the industry had evidence that cigarettes caused cancer and other negative health outcomes. Another involuntary disclosure was that the marketing and promotion strategies used by big tobacco targeted vulnerable groups like young people and the poor.
They used various techniques. In the US, for example, tobacco companies financially sponsored events hosted by African American community groups and supported civil rights causes. It was not unusual for them to provide free cigarettes to mental health facilities and homeless shelters or to distribute cigarette branded blankets to people living rough on the streets.
Similar grants and aid were given to Australian community social services. “Value” pricing and promoting images and flavours (menthol) that appealed to people living in deprived urban areas were also used.
Marketing cigarettes as a way to help you “cope with stress” was common. The entire strategy was labelled “downscaling” and today we are witnessing a globalisation of “downscaling” strategies where low and middle income countries have become the targets for the tobacco industry.
Unfortunately even in developed countries like Australia we continue to experience the effects of these strategies. A social gradient in smoking exists whereby smoking prevalence rates rise as one moves down the socioeconomic scale.
While the latest research from the Australian Institute of Health and Welfare shows that the adult smoking prevalence rate in the general community is about 15-18%, other data show that it is much higher in groups that may be labelled as socioeconomically disadvantaged and often not captured in health census surveys.
Population health surveys such as the recent Victorian Smoking Prevalence survey, using the Australian Bureau of Statistics indexes for socioeconomic status (the SEIFA index), indicate that rates of smoking are declining across socioeconomic groups, but these surveys do not capture people who are homeless, institutionalised, without phone access, or mentally or physically unable to respond to surveys.
Nonetheless, even in population surveys, like the Victorian survey, the socioeconomic gradient in smoking rates persist – the report shows that those who are in higher socioeconomic status postcodes have smoking rates of 11%, compared to 16% and 18% in those who live in middle and low socioeconomic postcodes.
Instead, reports focussing on including highly disadvantaged social groups show much larger differences in smoking rates – up to 50% of Aboriginal Australians smoke, 37% of single parents, 73% of homeless people and people with other drug disorders, 66% of people with a mental illness smoke and 60% of people accessing welfare aid from non-government agencies such as Anglicare and the Salvation Army.
The result is significantly poorer health amongst our most vulnerable people.
A recent article published in the Journal of the American Medical Association (JAMA) showed that four health behaviours (smoking, alcohol, physical activity and nutrition) explained 72% of social inequalities in all-cause mortality with smoking the strongest mediator.
In addition, smoking impacts on the cycle of social disadvantage taking income that may be better spent on life essentials like food and rent, causing financial stress, and social isolation for participating in a now stigmatised and often prohibited behaviour.
Public health efforts have resulted in the stunning reductions in smoking rates in countries like Australia, but there is more work to be done to reduce the social gradient in smoking rates.
In addition to mass media, taxation policies and the highly awaited and promising plain packs campaigns, which must continue, there is clearly a need for more targeted efforts that are tailored to the needs of smokers from socially disadvantaged backgrounds. There is good research evidence that employing targeted smoking cessation interventions can help smokers to quit.
There have also been suggestions that social change needs to occur in order to improve the conditions in which people live, work and play, to increase the likelihood of optimal health.
Smoking-related inequalities are related to broader social inequalities, and without addressing the latter we may not be able to eliminate the former. As Professor Siahpush has pointed out, social policies related to housing, education, unemployment, insurance and child protection can be regarded as tobacco control policies.
A special issue of the international addictions journal Drug and Alcohol Review has pulled together the latest research on this topic involving 18 of the top researchers in Australia and overseas.
The special issue showcases advances made in addressing inequities in smoking rates and improves our understanding of the challenges this presents.
One of the first Australian health organisations to rise to the challenge was the Cancer Council New South Wales, which launched its Tackling Tobacco Program in 2006 with the explicit aim of reducing social inequalities in smoking rates.
The program is the best representation of blending public health and social change to address this issue – it partners with social and community service organisations to provide support to their clients, who are people experiencing various forms of social and financial hardship, to quit smoking.
A number of papers published in the Drug and Alcohol Review special issue describe the successful outcomes of Tackling Tobacco pilot projects.
The special issue also includes contributions from researchers working in other non-health settings such as homelessness support services, prisons and juvenile detention as well as mental health and drug and alcohol treatment centres. While one contributor has called for a total ban of retail tobacco products, others have offered solutions such as harm minimisation.
The special issue is an important resource for anyone interested in tackling the social inequities in smoking rates.
The World Health Organisation has reported that action taken to reduce the health inequities associated with the social gradient in smoking rates will result in health, economic and social benefits for the whole of society. Both public health and social policy changes are needed.
• Associate Professor Billie Bonevski and Professor Amanda Baker are from the University of Newcastle School of Medicine and Public Health.