Reducing inequality in health

Who are ‘poor smokers’?

While discussion about ‘poor smokers’ often centres on the most deprived, The NHS Cancer Plan sets its national target to reduce smoking prevalence in ‘manual’ groups. It is true that the proportion of smokers is highest in the lower social classes, although the numbers of smokers in these groups is comparatively small. For example, smoking prevalence in social class E (or V) is 41% among men and 32% among women, but this represents only some 700,000 smokers (HDA/ASH, 2001). The proportion of smokers is highest in social classes D and E (See graphs, p20). The number of smokers is highest in the middle social classes (See graphs, p20).

Although the proportion of smokers is lower in social class C2 (or IIIM) – 32% of men and 30% of women in 1998 – the number of smokers exceeds three million, almost five times the number of those in social class E. So the target set in The NHS Cancer Plan has the advantage of producing the greatest health gain in the population. However, the seemingly intractable problem of smoking among the most disadvantaged must also be addressed.

Smoking and deprivation

The problem of smoking among the most disadvantaged in our society is daunting. For example, among lone parents living on benefits and in council housing, more than three-quarters smoke (Dorsett and Marsh, 1998). Moreover, recent research suggests that nicotine dependence is higher in people experiencing disadvantage (Jarvis and Wardle, 1999).

In keeping with these findings, the Independent Inquiry into Inequalities in Health recommended a short-term strategy to reduce nicotine dependence coupled with a complementary, longer-term strategy aimed at removing the cultural and environmental barriers that disadvantaged people face (Acheson, 1998). Community based interventions, brief advice from a general practitioner and specialised smoking clinics are also recommended as effective settings in which to provide NRT (Acheson, 1998). Bupropion (Zyban) is also now available on NHS prescription.

The available evidence indicates that a comprehensive tobacco control programme as set out in Smoking Kills, if efficiently and fully implemented, would bring down smoking in both manual and non-manual social classes. This is one of the conclusions of a joint HDA and Action on Smoking and Health (ASH) project on inequalities and smoking. The project has several elements including:

• A thematic discussion paper based on a review of the literature (Richardson, 2001)
• A rapid mapping exercise to identify existing and recent projects targeted at people living on low income and/or minority ethnic groups (Crosier, 2001)
• Secondary analysis of survey data to identify factors associated with quitting/not quitting among the most disadvantaged
• Qualitative research to identify low income consumers’ views of products and treatments (Jackson and Prebble, 2001)
• An expert seminar to seek consensus on what the evidence tells us
• Further discussion and a seminar with practitioners and policy makers.

The thematic discussion paper, the mapping exercise and a summary of the qualitative research are available at the HDA’s website . A very useful summary on inequalities and smoking, a product of this project, is available to download from the site or from ASH (HDA/ASH, 2001).

Clearly, some elements of a comprehensive policy, such as price policy, will be the responsibility of national authorities, but even these will have considerable impact on a local level. For example, the recent sharp increase in smuggled tobacco is mainly targeted on low income communities. This undermines the government’s price policy and compromises attempts to concentrate cessation help on low income smokers. Contraband tobacco is viewed positively in some deprived areas and is seen as a rational strategy to maintain levels of consumption (Wiltshire et al., 2001). Low income smokers may be slow in responding to national initiatives until more is done to address the material and personal factors that make it difficult for them to quit.

Community based projects

Attempts to set up community based projects to promote smoking cessation have met with mixed success. In a report of initiatives set up in low income communities in Scotland, the authors concluded that:

‘… small grant funding for time limited projects can promote work on smoking amongst women living or working in low income communities. Although reducing smoking was a long term goal for the majority of the initiatives most did not perceive themselves as a cessation group. As a result they did not measure success by the numbers quitting. Changes in individual smoking behaviours were noted and these ranged from extending the period of smoke free time, to restricting smoking to a specific room or location and trying nicotine replacement therapy.’ (ASH, Scotland, 1999)

Examples of other community based projects funded through small grants schemes can be found in Empowering smokers to quit: success principles for community stop-smoking projects (HEA, 1996b). The mapping exercise cited previously, which drew on this study, made several interesting observations about the nature of community based or mainstream projects. It reports finding a striking number of community smoking cessation projects given what was found in the literature, but the vast majority of these had been established by mainstream funding available after the publication of Smoking Kills. Only a very few – notably the innovative services established by the charity QUIT – had been established outside the NHS. This underlines the importance of sustained and dedicated funding.

One problem encountered with community projects is the difficulty of sustainability. With such an approach, a continuous, long-term effort is crucial to build understanding and commitment between the participants. Moreover, challenging and changing the cultural norms is a long-term process that requires careful planning and commitment of all agencies involved.

Black and minority ethnic groups

Little has been published on the impact of smoking cessation interventions in reducing tobacco use among black and minority ethnic groups in England. However, studies from the US suggest that they can be effective (Botvin et al., 1992; Elder et al., 1993; Lillington et al., 1995; Elder et al., 1996). In the absence of UK studies, patterns of tobacco use (HEA, 1999a) and research into tobacco’s role within and between black and minority ethnic groups (Maltby et al., 2000) can provide some pointers for the way forward. Examples of these are:

• The high rates of tobacco chewing, especially among Bangladeshis, suggest that this practice should be included in interventions aimed at reducing tobacco use
• Sensitivity to gender issues is vital
• Literature should be multi-lingual and in a style that is culturally familiar, eg use of vignettes to highlight health risks associated with tobacco use
• Information campaigns should be developed to redress misperceptions about tobacco use:
• eg belief that tobacco use can relieve indigestion
• eg belief that healthy practice in other areas such as diet and exercise will offset the detrimental effects of smoking

Ethnic differences in attitudes and beliefs about cigarette smoking should be incorporated into smoking cessation interventions. (Maltby et al., 2000; HEA, 1999a)

So to be successful, a tobacco cessation campaign must take account of the culture, tradition and religion of the particular target group. In so doing it will need to involve community groups, religious groups, smoking cessation coordinators, local tobacco alliances, primary healthcare teams, and culturally relevant local and national media, as well as key individuals within different ethnic groups.

Realted Articles

• NHS Cancer Plan
• Trends in smoking
• Features of effective interventions
• Local alliances in England
• Who to target: Young people or adults?
• Reducing inequality in health
• Components of a local strategy