Creating a Tobacco-Free Scotland: Addressing the Inequalities Challenge

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1 Creating a Tobacco-Free Scotland: Addressing the Inequalities Challenge Amanda Amos Centre for Population Health Sciences University of Edinburgh

2 Outline What are the issues and challenges- patterns and trends What works to reduce inequalities in smoking- evidence reviews Implications and conclusions

3 Percentage by gender Prevalence of regular cigarette smoking by sex in 15 year olds: Scotland (SALSUS) 40 Boys Girls

4 Social inequalities and youth smoking- Scotland (SALSUS 2010) Regular smokers: twice as likely to get free school meals more likely to live in the most deprived areas those living in the most deprived areas have higher levels of consumption

5 Smoking prevalence year olds Scotland ( )

6 Smoking prevalence in adults (16+) in Scotland (SHS) Men Women 5 0

7

8 Smoking and other forms of disadvantage Socio-economic status- education, income, employment Gender Ethnicity Lone parenthood Mental health problems Youth offenders, prisoners Unemployed Sexual orientation- lesbian, gay, bisexual Other excluded groups eg travellers, homeless

9

10 % adult (16+) smoking prevalence Adult (16+) smoking prevalence in Scotland by Scottish Index of Multiple Deprivation: 1999 to 2011 (actual), (target projections) SIMD 1 (most deprived) SIMD 2 35 SIMD SIMD 4 SIMD 5 (least deprived) Figure courtesy of ASH Scotland

11 What influences inequalities in smoking? Tobacco control policies and interventions focusing on prevention (youth), cessation (adults) and SHS protection (youth and adults) Patterns and trends in SES ie changes in socioeconomic status of populations and social determinants eg social/economic/ welfare policies, population shifts

12 Factors influencing quit rates by SES Motivation to stop- slightly lower Quit attempts- similar or slightly lower Support used- similar but drop out earlier Success rates- lower Dependence- higher levels of consumption, nicotine exposure and dependence Social and other factors- social norms, perceived role of smoking, low self-esteem, low self-efficacy, more negative life events

13 Action International- FCTC, EU Directives National- UK, Scotland Local- NHS, LAs, TSs, third sector, communities, schools, retailers, etc

14 Dual approach to tobacco control- prevention, cessation and protection Reduce supply access availability affordability Reduce demand individual aspirations and desirability (eg positive image, beliefs, role) social norms (eg acceptability, smoking-related attitudes and behaviour, quit attempts, SHS) addiction (cessation, harm reduction?)

15 Evidence on equity impact of tobacco control- SILNE Three systematic reviews- youth (11-25), adults (18+) population level, adults (18+) individual level Stage 4 and WHO European countries All types of interventions, study design and length of follow-up Reported differential smoking-related outcomes for at least 2 socio-economic groups English language journal articles and grey literature Over 30,000 papers and reports

16 Assessment of equity impact Positive equity impact - low SES groups relatively more responsive to the intervention Neutral equity impact- no social gradient in the effectiveness of the intervention i.e. same impact on high and low SES groups Negative equity impact - high SES groups relatively more responsive to the intervention Mixed equity impact- varied by SES measure and/or gender, setting, outcome measure Unclear equity impact- not clear e.g. no statistical analysis by SES group

17 Summary equity impact- Youth Increases in price/tax of tobacco products Positive Neutral Negative Mixed Unclear Total Smokefree- voluntary, regional, partial Smokefree- compulsory, national, comprehensive Mass media campaigns Controls on advertising, promotion, marketing of tobacco Controls on access to tobacco products Schools-based prevention Multiple policies Individual smoking cessation support Individual-level support for smokefree homes Total studies

18 Results- youth 38 studies evaluated 40 interventions/policies The equity impacts: 7 positive, 16 neutral (most benefited all SES groups), 12 negative, 4 mixed, 1 unclear Price/tax increases had the most consistent positive equity effect (4 of 7 studies) (i.e. reduced inequality) There is little available evidence to inform tobacco control policy and interventions aimed at reducing socioeconomic inequalities in youth smoking

19 Summary equity impact- adults population level Positive Neutral Negative Mixed Unclear Total Increases in price/tax of tobacco products Smokefree voluntary, regional, partial Smokefree compulsory, national, comprehensive Mass media cessation campaigns Mass media campaigns to promote quitlines and NRT Controls on advertising, promotion and marketing of tobacco Population-level cessation support Settings based interventions Multiple policies * Total studies 31** ** 117 *Eight studies assessed more than one type of policy; **one study was unclear for price/tax and positive for Mass media cessation campaign

20 Results- adults population level 117 studies evaluated 130 interventions/policies The equity impacts: 33 positive, 36 neutral (most benefited all SES groups), 38 negative, 6 mixed and 17 unclear The clearest and most consistent evidence of a positive equity impact was for price/tax increases (14 of 27 studies) Only one study evaluated a non-tobacco control policy Only limited conclusions can be drawn about which types of tobacco control interventions are likely to reduce inequalities in smoking

21 Summary equity impact- adults individual cessation support (Europe) Behavioural and pharmacological Positive Neutral Negative Unclear Total Behavioural Pharmacological Brief advice Quitlines and Quit & Win campaigns Text based Internet based Total

22 Results- adult individual cessation support in Europe 29 studies The equity impact on quitting rates: 0 positive, 10 neutral (most benefited all SES groups), 18 negative, 1 unclear Overall positive equity impacts were observed only in the UK targeted smoking cessation services, where the higher relative reach of services among disadvantaged smokers more than compensated for relatively lower quit rates Cessation services in Europe not targeted at low SES smokers are likely to have increased inequalities in cessation

23 Conclusions (1) Increased tobacco control action has led to significant declines in smoking prevalence but no decline in inequalities in smoking We know what works to reduce smoking uptake and increase cessation We know much less about what works to reduce inequalities in smoking, particularly in young people Many types of tobacco control either increase or have no effect on inequalities in smoking

24 Conclusions (2) What does work are real tax increases- but beware of unintended consequences Need more research on developing more effective equity-oriented tobacco control strategies Need both comprehensive policies (eg price, standardised packaging) and tailored interventions (eg cessation support, mass media) targeted at low SES groups Need bold and radical action to reduce supply and demand

25 Scottish Youth Commission on Smoking Prevention Some recommendations for action: standardised packaging ban smoking in cars increase age of sale to 21 in 2031 ban sales to people born after m ban smoking around schools novel school and media approaches ban e-cigs for under18s involve young people in co-designing interventions and cessation services

26 Other action Reducing number of tobacco retail outlets Reducing the profitability of selling tobacco Cessation support??? BUT may be limits to what can be achieved by tobacco control alone- also need to address social determinants of inequalities

27 Acknowledgements ASH Scotland Tamara Brown Sarah Hill Steve Platt

28 Thanks

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