Smoking: an issue of social justice

Transcription

1 Smoking: an issue of social justice Smoking and Disadvantage Seminar, CCWA 31 st May, 2012

2 There is a lot of death and suffering ahead of us, but it will be concentrated among those already suffering the most Professor Ron Borland, Oceania Tobacco Control Conference, 2011

3 Session outline What makes smoking a social justice issue? -prevalence - impacts - drivers and barriers Disparities - do they matter? Reducing the burden of tobacco on the disadvantaged - what actions are needed?

4 Any marker of disadvantage that can be envisaged, whether personal, material, or cultural, is likely to have an independent association with cigarette smoking Jarvis and Wardle, 2006

5 Smoking careers Graham et al, 2006 Childhood Childhood adversity Adolescence Early school leaving Low educational attainment Adulthood Poor adult circumstances Early mothering Single parenting

6 Affects of early childhood adversity Shonkoff et al, 2011 Early Childhood Adversity Toxic stress Disruption of brain circuitry physiologic dysregulation of brain and organ systems - Hyperresponsive, chronically - activated stress response - Impairs mood control, cognition, - social, emotional skills - Elevated fear, anxiety - Decrease in immune function - Increase in inflammatory - markers - Wear and tear of organ systems Adoption of unhealthy lifestyles as coping mechanism: -Tobacco -Alcohol -Illicit drugs Increased risk in adult life of : - Cardiovascular disease - Liver cancer -COPD - Autoimmune diseases

7 Smoking rates - disadvantage AIHW, 20011; ABS, 2008; Morgan, Wattereus, Jablensky et al., 2011; Lawrence, Mitrou & Zubrick, 2009;

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9 Causes of preventable deaths, Australia 2003 Smoking Breast Cancer Infectious and parasitic diseases Suicide Drug dependence Falls Road traffic accidents Alcohol dependence (inc cirrhosis) Poisoning Homicide and violence Drowning AIDS Reference: Australian Institute of Health & Welfare 2007

10 Health impacts Smoking accounts for: more than half the difference in mortality (for men) between those in top and bottom social strata (indirect methods) 21% (men) and 11% (women) of the mortality gap between those with and without post school quals (direct methods) 17% of the health gap between indigenous and nonindigenous Australians 20% of all deaths among adult indigenous Australians Jha et al, 2006; Blakely et al, 2005; Vos et al, 2008; CEITC, 2008

11 Health impacts The scope for reducing health inequalities related to social position is probably limited unless many smokers in lower social positions can be enabled to stop smoking Gruer et al. Effect of tobacco smoking on survival of men and women by social Position: a 28 year cohort study. BMJ 2009; 338: doi: /bmj.b480

12 The bottom fifth of households were spending nearly a fifth (18.5%) of their total household income on smoking

13 Financial impacts Less money for essentials like food, accommodation Smokers twice as likely to report severe financial stress (going without meals, no heating) Children in smoking households more likely to experience food insecurity Smokers with serious mental illness spending from one quarter to one third of income on cigarettes Sources: Siahpush et al, 2003; Siahpush et al, 2005; Cutler-Triggs et al, 2008; Steinberg et al, 2004;Lawn, 2001

14 I ve got an extra 70 bucks a week in my pocket. Vic, in drug and alcohol recovery

15 A host of external factors affects whether or not individuals start to smoke, whether or not they attempt to quit and whether or not any quit attempts are successful Voigt 2010, p 3.

16 Factors relating to personal and social circumstances Greater nicotine dependence Normalisation of smoking - modeling by parents/peers - surrounded by smokers in community Oh it s all around you and you have that first puff and then it s like, I ll just have one... Good friends give you cigarettes and you can t say no Jarvis and Wardle, 2006; Griesbach et al, 2003; Urbis, 2007

17 Factors relating to personal and social circumstances Exposure to difficult and stressful circumstances I need it to stress less and yeah, take my mind off a lot of things Smoking as a means of coping with these circumstances Relief Respite Comfort Company MacAskill et al, 2008; Stead et al, 2001; Bryant et al, 2010 Milton et al, 2012.

18 Factors relating to personal and social circumstances Lack of personal support to quit Misconceptions about quit services/medications Lack of access to and cost of NRT Lack of confidence/optimism MacAskill et al, 2008; Pisinger et al, 2010; Bryant et al. 2010; Roddy et al, 2006; Stewart et al, 1996; Marsh 1997.

19 Smoking rates UK multiple disadvantage vs relative advantage Multiple disadvantage More affluent

20 IV drug user daily smoking (n = ~ 850) Stafford, J. et al Australian Drug Trends 2011

21 Disparities: Do they matter? Evidence that disparities are increasing But this is probably inevitable- Zhu s thesis on relative disparity Disparities are a catalyst to action signal need for new strategies alongside established ones Focus should be on reducing prevalence among the most disadvantaged as quickly as possible Pisinger et al, 2010;Jarvis and Wardle, 2006; Sharma et al, 2010, Zhu et al 2010, Lawrence et al, 2011; Baker et al, 2006.

22 What actions are needed? Three broad options: Address the underlying social conditions (education, employment, income, housing) Maintain effective whole of population approaches (legislation, tax, mass media) Apply strategies targeted to most disadvantaged (more intense quit support, local social marketing) Principles: Equity as well as efficiency; extra help for those with extra need

23 A mix of strategies. Continue effective whole of population strategies - Tax, regulation, mass media campaigns, brief advice by GP s Support efforts to address social conditions: - Allies with those calling for progressive social policy Additional strategies to reach most disadvantaged: - Targeted and local social marketing to de-normalise smoking - Better access to affordable NRT (all types), maintenance? - System wide integration of smoking care in government run human services (mental health, D&A, prisons) - Smoking care capacity building in NGO services - Face to face services in areas with sufficient demand - Welfare payment incentives? Marsh, 1997; Paul et al 2012

24 Conclusions The multiply disadvantaged bear a disproportionate share of the harms imposed by smoking Their circumstances result in increased drivers to smoke and magnified barriers to quitting Additional strategies are required to reduce smoking among the most disadvantaged, many of whom will need extra help to quit

25 One response Tackling Tobacco Program

26 Barriers to quitting- organisational Lack of access to/use of appropriate support services Affordability and ease of access to NRT Assumptions by health/welfare workers - don t want to quit - can t quit - unfair to ask when quitting other drugs

27 Lifetime quit rate US 50% Lifetime quit rate homeless US 9% Implication: the most disadvantaged will need extra help to quit References: Baggett & Rigotti, 2010

28 Comparison, tobacco smoking status ATSI aged 18years and over, general population aged 14 years and over, general trends % general population aged 14yrs and over Absolute reduction Relative reduction % ATSI aged 18yrs and over Absolute reduction Relative reduction Source: National Drug Strategy Household Survey, AIHW, 2011 CEITC data from NATSIS (1994) NATSISS (2002) NATSIHS (2004) NATSISS (2008)

29 Terms and definitions Low SES Disadvantaged groups Poor smokers Deprived groups The vulnerable Marginalised populations Low-income groups Hard to reach populations The most disadvantaged Minority populations Underclass of smokers Sub-populations with multiple social and health disadvantages No definition Various indicators of SES (employment, education -early school leaving, higher education, adult disadvantage- reliance on benefits) Some measures by tertile, some by quartile, some by quintile Townsend index of deprivation (unemployment, car ownership, housing tenure, overcrowding) Mosaic- UK geodemographic classification system using 400 variables of demographics, lifestyle factors and behaviours More nuanced indicators find greater disparity in smoking rates

30 Different views or different groups in view? Research shows that different racial and socioeconiomic groups respond equally well to quit campaigns Chapman, 2011 Studies have shown that increasing the price of cigarettes results in a larger decrease in smoking prevalence among lower income groups Anti smoking mass media campaigns are equally effective among lower socio-economic groups Siahpush, 2011 It appears that tobacco control activities have had less success among people living in poverty, certain racial and ethnic minorities and indigenous populations, prisoners, pregnant teenagers, people with mental illness, people without family supports and people with limited educational attainment Lawrence, Mitrou and Zubrick, 2011