Existing interventions and programs to reduce levels of smoking among disadvantaged groups

Informed by an emerging body of evidence, there is a growing interest in Australia in addressing the disparities in smoking rates between population groups. The National Tobacco Strategy 2012-2018 61 demonstrates a strong commitment to reducing the social and health inequalities associated with tobacco. Reducing smoking rates in populations with high prevalence of smoking has been highlighted as one of the nine priority action areas.

Evidence indicates that smoking cessation can reduce health and economic disparities.(48, 49, 62) Quitting smoking improves a person’s finances by releasing funds spent on tobacco, and also through health improvements which may reduce disability and incapacity to work or care for others.(62) However, there is limited published research on effective strategies for reducing smoking in highly disadvantaged groups.

What works?

Population wide strategies such as tax increases,(63-65) mass media (66, 67) and smoke-free legislation have been shown to be effective in reducing smoking across all socio-economic groups (68) and have had a greater impact on people from lower socio-economic groups.

• There is strong evidence for increased taxation as a policy to reduce tobacco related disparities. A review of population tobacco control interventions concluded that “increasing the price of tobacco is therefore the population intervention for which we found the strongest evidence as a measure for reducing smoking-related inequalities in health.” (p.235) (63) Taxation has been shown to prompt quit attempts and reduce consumption of tobacco.(69-71)
• Evidence shows that mass media anti-smoking campaigns prompt help-seeking behaviours such as calling the Quitline, increase quit intentions, increase cessation activity and reduce smoking rates.(66)
• There is strong evidence that smoke-free legislation prompts quit attempts and reductions in consumption.(72) Research has shown that comprehensive smoke-free policies covering workplaces and venues like bars and clubs, as well as cigarette price increases, are as likely to discourage smoking among low socio-economic status (SES) groups as among high SES groups.

Population-wide strategies reduce uptake and experimentation of smoking among adolescents across all socio-economic groups, in particular adolescents from low socio-economic groups. During a period of low tobacco-control funding and activity in Australia (1992-1996) smoking prevalence increased among 12-to-15 year olds; however, the greatest increase was among lower socio-economic groups.(74)

What looks promising?

Several themes are emerging from the literature looking at more targeted approaches to reducing smoking rates. There is a growing body of literature exploring the merits of encouraging better use of existing cessation services and treatments in disadvantaged population groups and integrating smoking cessation support into social and community service settings. Both have an emphasis on tailoring cessation support to the social and cultural circumstances of the smoker.

Figure 2: A summary of population-wide tobacco strategies and their impact on low income groups Tax increases Higher cigarette price is associated with lower prevalence of smoking. Lower income groups are more responsive to price. A 10% rise in price resulted in a 3.2% decline in prevalence among low income smokers. Anti-smoking media campaigns Highly emotional anti-smoking advertisements generate greater recall, are perceived as more effective and influence smoking beliefs and increase quit attempts. People in low SES groups are particularly responsive to emotional or personal testimonial advertisements. Greater exposure to these advertisements is associated with greater likehood of quitting. For each 10 additional exposures the odds ratio of quitting is 1.15 times as high. Smoke-free legislation and policy Smoke-free policies prompt quitting and reductions in tobacco consumption across all socio-economic groups. Smoke-free pubs and clubs have been shown to have a bigger impact on lower SES population with reductions in consumption reported by 40% of smokers. Smoke-free workplaces reduce social inequalities in secondhand smoke exposure.

Encouraging better use of existing cessation services and treatments in groups with high smoking prevalence

Improving access to tools that are known to help people quit (i.e. counselling, quitting medications and behavioural interventions) may represent the most promising approach for reducing smoking rates in disadvantaged groups.(75)

• There is robust evidence that the chances of quitting successfully are increased when using quitting medications in combination with supportive counselling. (76-78) Quitting medications are particularly effective in smokers with high nicotine dependence.
• There have been numerous studies exploring the efficacy of evidence-based treatments such as pharmacotherapies, quit counselling, motivational interviewing and brief interventions in disadvantaged population groups.(5, 79, 80)There is strong evidence for the acceptability of these interventions within these groups and also evidence for successful quit attempts.
• Some groups have been researched more than others. There are numerous studies and reviews studying people with a mental health issue (79, 81-84) and drug and alcohol issues.(85, 86) For other population groups such as people who are homeless,(46, 87,113) prisoners(88) and Aboriginal and/or Torres Strait Islander peoples (89, 90) there are only a small number of studies with small sample sizes. However, these studies provide some evidence that pharmacotherapies, cessation counselling, brief interventions and organisational smoke-free polices can assist these groups. This evidence is summarised in Figure 3.

Figure 3: Tobacco Interventions for Disadvantaged Groups: A Summary of Evidence

POPULATION GROUP	PHARMACOTHERAPIES	PHARMACOTHERAPIES AND QUIT COUNSELLING/SUPPORT	MOTIVATIONAL INTERVIEWING AND BEHAVIOURAL INTERVENTIONS	ORGANISATIONAL SMOKE-FREE POLICIES
ABORIGINAL AND  TORRES STRAIT ISLANDER PEOPLES	SHOWS PROMISE	SHOWS PROMISE	NO EVIDENCE PUBLISHED TO DATE	NO EVIDENCE PUBLISHED TO DATE
PEOPLE WITH MENTAL HEALTH ISSUES	STRONG EVIDENCE	STRONG EVIDENCE	STRONG EVIDENCE	STRONG EVIDENCE
PRISONERS	SHOWS PROMISE	SHOWS PROMISE	NO EVIDENCE PUBLISHED TO DATE	SHOWS PROMISE
PEOPLE WITH  SUBSTANCE USE DISORDERS	STRONG EVIDENCE	STRONG EVIDENCE	STRONG EVIDENCE	STRONG EVIDENCE
PEOPLE EXPERIENCING HOMELESSNESS	SHOWS PROMISE	SHOWS PROMISE	SHOWS PROMISE	NO EVIDENCE  PUBLISHED TO DATE

Although the research demonstrates that smoking cessation support services and pharmacotherapies work with a range of population groups, it has been found that people facing multiple disadvantage have poorer access to these services.(91, 92) The challenge is to find ways to improve access to cessation methods.

• When quitting medications are subsided or free, use by disadvantaged smokers increases.(93, 94)
• Offering free or low-cost NRT has been shown to increase calls to Quitline.(95) A trial intervention conducted in Australia, which offered subsidised NRT in addition to a Quitline service, found that the offer of subsidised NRT recruited double the number of low-income smokers, compared to the offer of the Quitline service alone.(96)
• Since February 2011 the Australian Government has made a range of pharmacotherapies available on the PBS thus substantially reducing the cost. This has resulted in a high uptake in low income groups (76.4% of prescriptions for the nicotine patch were for concessional card holders).(97)
• Better use of existing quit services can be encouraged through promoting direct referrals from health and social and community service organisations and delivering cessation support that is sensitive to the diverse needs of different population groups.(98)
• Programs are more successful when tailored to the local environment and local needs of different population groups. Key elements include:
  • a non-judgmental, holistic and empowering approach; (40)
  • delivery that recognises the role of smoking in people’s lives and the other issues they are facing; (45, 75, 99)
  • provision of social support, flexibility and accessibility; (40, 100)
  • well-trained staff; (40, 101) and
  • for Aboriginal and/or Torres Strait Islander communities, consideration of family and community factors, in addition to supporting the individual.(50, 60)

Integrating smoking cessation support into social and community service settings

Social and community service providers such as mental health facilities, drug and alcohol services, family services, and services for homeless people cater for populations with high smoking rates. They have been identified as ideal settings and partners in reducing smoking rates in disadvantaged groups.(102, 103) Bringing cessation services to disadvantaged smokers in familiar environments has been recommended as a vital strategy to increase utilization of cessation methods as it has been argued that these groups are unlikely to seek support elsewhere.(104) There is a growing body of research in Australia and internationally exploring the role of these services in tobacco control.

• Surveys of smokers who are clients of community services indicate they are open to receiving smoking cessation assistance from these services as they are a trusted source of advice and support and can offer more personalised support.(92, 100, 104-106)
• The integration of smoking cessation support in organisations already working with disadvantaged groups has been shown to be effective in decreasing smoking rates.(82, 107-109)
• Adoption of smoke-free policies by social and community service providers encourages a change in beliefs and behaviour about the acceptability of smoking and reduces triggers for relapse.(91, 109-111)
• Recommended approaches for social and community service providers include: (59, 104, 106, 110-112)
  • reviewing and revising organisational smoke-free policies;
  • changing practices to de-normalise smoking;
  • supporting staff to quit;
  • training staff to build their confidence in delivering smoking cessation advice or referrals;
  • making active quit support a part of clients’ routine care, including asking them about their smoking and interest in quitting, and providing active referrals to Quitline; and
  • changing systems to record and monitor smoking status.

Key points

• Tax increases, mass media anti-smoking campaigns and smoke-free legislation actively reduce smoking rates in all population groups including low-income and disadvantaged groups and have a vital role in preventing the widening of disparities in smoking.
• Pharmacotherapies, cessation counselling, brief interventions, and smoke-free policies are effective in disadvantaged population groups.
• There is merit in tailoring cessation services to the different needs of disadvantaged population groups and delivering cessation strategies in the organisations accessed by these groups.
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