Creating a Tobacco-Free Scotland: Addressing the Inequalities Challenge Amanda Amos Centre for Population Health Sciences University of Edinburgh
Outline What are the issues and challenges- patterns and trends What works to reduce inequalities in smoking- evidence reviews Implications and conclusions
Percentage by gender Prevalence of regular cigarette smoking by sex in 15 year olds: 1982-2010 Scotland (SALSUS) 40 Boys Girls 30 20 10 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
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
Smoking prevalence 16-24 year olds Scotland (1999-2006)
Smoking prevalence in adults (16+) in Scotland (SHS) 35 30 25 20 15 10 Men Women 5 0
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
% adult (16+) smoking prevalence Adult (16+) smoking prevalence in Scotland by Scottish Index of Multiple Deprivation: 1999 to 2011 (actual), 2012-2036 (target projections) 50 45 40 SIMD 1 (most deprived) SIMD 2 35 SIMD 3 30 25 20 15 10 5 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 SIMD 4 SIMD 5 (least deprived) 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 Figure courtesy of ASH Scotland
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
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
Action International- FCTC, EU Directives National- UK, Scotland Local- NHS, LAs, TSs, third sector, communities, schools, retailers, etc
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?)
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 1995-2013 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
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
Summary equity impact- Youth Increases in price/tax of tobacco products Positive Neutral Negative Mixed Unclear Total 4 1 2 0 0 7 Smokefree- voluntary, regional, 0 4 1 1 0 6 partial Smokefree- compulsory, 0 2 4 0 0 6 national, comprehensive Mass media campaigns 0 0 0 1 0 1 Controls on advertising, 0 2 2 0 0 4 promotion, marketing of tobacco Controls on access to tobacco 2 2 1 0 0 5 products Schools-based prevention 0 2 1 1 1 5 Multiple policies 0 2 0 1 0 3 Individual smoking cessation 1 1 0 0 0 2 support Individual-level support for 0 0 1 0 0 1 smokefree homes Total studies 7 16 12 4 1 40
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
Summary equity impact- adults population level Positive Neutral Negative Mixed Unclear Total Increases in price/tax of tobacco 14 6 4 1 2 27 products Smokefree voluntary, regional, 1 1 19 0 4 25 partial Smokefree compulsory, national, 2 9 6 1 4 19 comprehensive Mass media cessation campaigns 3 2 5 2 6 18 Mass media campaigns to promote 5 3 3 0 1 12 quitlines and NRT Controls on advertising, promotion 2 7 0 0 0 9 and marketing of tobacco Population-level cessation support 4 2 0 1 2 9 Settings based interventions 2 4 1 0 0 7 Multiple policies 0 2 0 1 1 4 33 36 38 6 17 130* Total studies 31** 30 37 6 14** 117 *Eight studies assessed more than one type of policy; **one study was unclear for price/tax and positive for Mass media cessation campaign
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
Summary equity impact- adults individual cessation support (Europe) Behavioural and pharmacological Positive Neutral Negative Unclear Total 0 4 12 1 17 Behavioural 0 1 4 0 5 Pharmacological 0 0 1 0 1 Brief advice 0 1 0 0 1 Quitlines and Quit & Win campaigns 0 1 1 0 2 Text based 0 1 0 0 1 Internet based 0 2 0 0 2 Total 0 10 18 1 29
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
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
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
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 2013 50m ban smoking around schools novel school and media approaches ban e-cigs for under18s involve young people in co-designing interventions and cessation services
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
Acknowledgements ASH Scotland Tamara Brown Sarah Hill Steve Platt
Thanks