Smokefree Action: Health Inequalities

Smoking is a major and growing factor in health inequalities. It is already responsible for half the difference in life expectancy between those in the highest and lowest socioeconomic groups.(1)

Death rates from tobacco is three times higher among those in lowest socioeconomic groups (2) and there is a stark and growing gap in smoking prevalence between socioeconomic groups, with those in routine occupation being twice as likely to smoke as those in professional occupation.

A recent study in Scotland (3) found the least affluent “never-smokers” live longer than even the most affluent smokers. Taking smoking out of the equation, the differences in survival between the highest and lowest socioeconomic groups are relatively small, especially for women. Even if the socio-economic circumstances of less well-off smokers improve, their health gain is likely to be minimal if they continue to smoke.

Preventing people from starting to smoke and helping those who do to quit requires measures at population level that impact on all the key levers, price, promotion, place and product, (also known as the marketing mix).(4)

There is a clear social gradient in smoking: smoking rates are markedly higher among those is lower socio economic groups than among those in higher socio economic groups. In 2003, 15% of men in higher managerial occupations smoked, compared with 39% in routine occupations.(5)

Despite a reduction in the overall prevalence of tobacco smoking in the UK over the past 30 years, there has been a slower reduction in smoking rates among lower income groups, and little or no change over the past decade.

Traditional measures of social class tend to underplay the extent to which smoking has become concentrated in the lowest socio economic sections of society. Studies of deprived and disadvantaged groups have shown smoking levels among lone parents in receipt of social security benefits in excess of 75%.(6) Smoking prevalence among prisoners is estimated to be over 80% (7) and smoking rates among vendors of the Big Issue were found to be over 90%.(8)

smoking by sex and socio economic group graph

People in lower socio economic groups consume more tobacco than more affluent smokers. Smokers in routine and manual groups consume on average 15 cigarettes per day compared with smokers in managerial and professional groups who consume 13 cigarettes per day.(5) There is also evidence that poorer smokers consume more tobacco from each cigarette smoked – either by smoking cigarettes with a higher tar yield, by leaving a shorter stub or by drawing harder on the cigarette.

A smoking habit of 20 cigarettes per day costs between £1,600 and £1,800 per year. Poorer smokers spend a disproportionately large share of their income on cigarettes compared with more affluent smokers. In 2003 the poorest 10 per cent of households spent 2.43 per cent of income on cigarettes per week, whilst the richest 10 per cent of households spent 0.52 per cent.(9) Among the most deprived groups – including lone parents in receipt of state benefits – three out of four families smoke and spend a seventh of their disposable income on cigarettes.(6)

Much of the reduction in smoking prevalence over the past 30 years has come about as a result of better off groups giving up smoking. All available evidence indicates that the desire to give up is similar across social groups. Around two thirds of smokers want to stop smoking.(5) But poor smokers find it hardest to quit. Rates of stopping smoking are three times lower among the least well off in society, compared with the wealthiest.(10)

NHS Stop Smoking Services are a very cost effective means of targeting nicotine addiction. A recent analysis shows NHS stop smoking service as being one of the most cost effective interventions with the average cost per life gained for every smoker under £700.

Evaluation of these services has established that they are more effective at reaching those smokers in the lowest socio economic groups.(11) This is supported by figures from the Office of National Statistics studies which show that in 2005 8% of routine and manual workers said they had been referred or had self referred to a stop smoking service, compared to 4% of professional and managerial workers.

support for 20p tax increase in cigarette price graph

Increasing the price of tobacco through taxation has proved to be the most effective way of helping people quit.(12),(13)

A recent YouGov poll commissioned by ASH in February 2008 found that 64% supported an increase in tobacco taxation as policy measure.

However this poses a dilemma: tobacco tax tends to hit the poorer people harder, and while it helps some smokers quit and makes substantial health and welfare gains, it can leave those in the lowest socio economic groups who fail to quit facing greater disadvantage. That is why we must make the greatest possible effort to help smokers to quit in response to increases in taxation.

To encourage more smokers to quit, HM Treasury reduced VAT on nicotine replacement products from 17.5% to 5% for one year from July 2007 and in the 2008 Budget the Chancellor agreed to extend the reduced tax rate indefinitely. This has had a positive impact on sales.(1)

Mass media interventions are highly cost-effective on a per capita basis. Advertising campaigns have been found to be an effective means of reducing smoking and can be targeted to tackle health inequalities of lower economic groups, but they must be sustained to have a high impact.

Mass media campaigns are integral for addressing smoking in the home and other private places such as cars, which remain the major source of secondhand smoke exposure for children in the United Kingdom. The most effective means in reducing exposure to children is through restrictions on smoking at home which are currently only imposed by less than 20% of households.

(1) Wanless D (2004) Securing Good Health for the Whole Population. London: TSO

(2) Acheson, D. Independent Inquiry into Inequalities in Health. London, TSO, 1998

(3) Laurence Gruer, Carole Hart, David Gordon, Graham Watt Smoking and health inequalities: new insights from Renfrew and Paisley 2007

(4) http://en.wikipedia.org/wiki/Marketing_mix

(5) Office for National Statistics (2004). General Household Survey 2003/04. http://www.statistics.gov.uk/ghs

(6) Marsh A and McKay S (1994) Poor Smokers. London: Policy Studies Institute
Department of Health (2004) Choosing Health: Making Healthier Choices Easier. London: Department of Health

(7) Big Issue (2002). Coming Up from the Streets: What Big Issue Vendors Need to Escape Homelessness. Vendor Survey October 2002. Cardiff: The Big Issue Cymru.

(8) ONS (2004) Family Spending. A report of the 2002/03 Expenditure and Food Survey

(9) ONS (2004) Family Spending. A report of the 2002/03 Expenditure and Food Survey

(10) Jarvis, M. (1997). Patterns and predictors of smoking cessation in the general population. In Bolliger, C.T., and Fagerstrom, K.O. (Eds), (1997). The Tobacco Epidemic. Progress In Respiratory Research, 28, 151-164

(11) Chesterman, J. Judge, K. Bauld, L & Ferguson, J. How effective are the English smoking treatment services in reaching disadvantaged smokers? Addiction, 2005; 100 (Suppl.2), 36-45.

(12) Jha P, Chaloupka FJ. Curbing the Epidemic:Governments and the Economics of Tobacco Control. World Bank, 1999.

(13) Hu T-W, Sung H-Y, Keeler TE. Reducing cigarette consumption in California: tobacco taxes vs. an antismoking media campaign. Am J Public Health 1995b;85(9):1218-22