Achieving Equity to Eliminate Tobacco‐Related Disparities

Progress in tobacco reduction is one of the most significant public health successes of the past few decades, however the benefits of this success have not been felt equally across Canadian society. Research shows that as tobacco use has decreased in the general population, it has also become disproportionally concentrated within the least‐privileged population groups in our province.1,2,3,4 As a result, tobacco use is a significant contributor to the health equity gap between socio‐economic groups in Alberta. In order to improve health equity in Alberta, tobacco reduction must be a public policy priority with a focus on policies that are proven to decrease tobacco use inequalities.

Socio‐economic status and tobacco use

Tobacco use‐related disparities are the differences that exist between population groups with regard to key tobacco use‐related indicators, including (1) behaviour patterns, prevention, and the treatment of tobacco use; (2) the risk, incidence, morbidity, mortality, and burden of tobacco‐related illness; and (3) the capacity, infrastructure, and access to resources; and (4) secondhand smoke exposure.5 Throughout Canada and around the world, there is a clear inverse relationship between tobacco use and socio‐economic status.6,7,8,9 Whether comparing income, education, occupation level, or other socio‐economic indicators, the least privileged population groups demonstrate a tendency to start smoking at a younger age, to smoke more cigarettes per day, and to be less likely to stop smoking compared to those who are more privileged.10 The distinction has become so pronounced that some of the most disadvantaged members of society are exhibiting smoking rates double the rates of the general population,11 and quit rates that are one‐half of those of the highest socio‐economic groups.12 In one Canadian study, the odds of smoking were almost four times higher among those who had not completed secondary school compared to those with a university degree.13

Tobacco use disparities are also translating into health disparities. In Canada, populations with the lowest income have COPD hospitalizations rates triple those of the highest income earners.14 Another study from the United Kingdom revealed that smoking‐related death rates are 2 to 3 times higher in the most disadvantaged groups than among those who are less disadvantaged.15

An issue of equity

The distinction between population groups is much narrower when it comes to intentions to quit and actual quit attempts.16 This supports the assumption that most disadvantaged members of society desire a tobacco free life as much as anyone else. These populations’ higher smoking rates exist because of issues of equity such as a lack of access to cessation supports, unfavourable policies such as suppressed tobacco taxes, and a lack of supportive environments where they live, work and recreate. Vulnerable population groups in Alberta need better protection from tobacco related harms and more support when trying to quit.

What is perhaps most troubling is that tobacco use‐related inequalities appear to be some of the only health‐related inequalities in Canada that have been increasing over the last 10 years.17 Inequalities in tobacco use are also larger among younger adults than older adults,18 indicating that the widening gap is not likely to correct on its own. Public health initiatives to reduce tobacco use have had more success among medium and high socioeconomic groups and need to be better tailored to reach the least advantaged population groups. It is also important to note that inconsistent adoption and enforcement of tobacco reduction policies create disparities in protections from tobacco, secondhand smoke exposure and support for cessation.19

How tobacco reduction reduces health inequities

Health equity can be achieved in tobacco reduction by eliminating differences in tobacco use and exposure to secondhand smoke between groups. Well‐enforced and comprehensive tobacco reduction policies and programs can reduce these disparities.20 Tobacco reduction policies that focus on large‐scale, population‐level changes have the potential to influence and change social norms related to tobacco initiation, tobacco use, and secondhand smoke exposure. Comprehensive tobacco reduction policies help achieve health equity by reducing disparities among groups most affected by tobacco use and secondhand smoke exposure, addressing the factors that influence tobacco‐related disparities and creating a significant return on investment.21

Tobacco reduction policies that lead to health equity

To ultimately eliminate tobacco use‐related health disparities, tobacco reduction programs and policies must be implemented in a way that achieves equitable benefits for all.22 Reducing the prevalence of tobacco use requires greater attention to populations carrying a disproportionate burden of use and dependence. Policies that focus on adolescence and young adulthood, a time when most people begin using tobacco, are especially important to reduce tobacco‐related disparities. Policies to reduce tobacco‐related disparities include:23

  • Increasing the price of tobacco products;
  • Increasing the number of people protected by comprehensive smoke‐free laws;
  • Reducing exposure to targeted tobacco industry advertising, promotions, and sponsorship; and
  • Improving the availability, accessibility, and effectiveness of tobacco cessation services for populations affected by
    tobacco‐related disparities.

Tobacco taxes improve health equity

Supressed tobacco taxes result in more tobacco use among low‐income populations causing these populations to bear a disproportionate share of the burden of the health and economic consequences of tobacco use resulting in an increase in the likelihood of poverty.24 Evidence also shows that increasing the price of tobacco products can reduce tobacco‐ related disparities among different income groups as low‐income populations are more responsive to tax and price increases.25 For maximum impact, tobacco tax increases need to be accompanied by investments in effective smoking cessation programs that are targeted to at‐risk population. People within lower socioeconomic groups are two to three times more likely to quit or cut back on their tobacco consumption as a result of the increased costs of tobacco products.26,27 By quitting or cutting back tobacco consumption, adults in these populations also provide a further benefit to children and youth by modelling healthy behaviours and providing a tobacco‐free environment, thus reducing exposure to tobacco smoke and reducing the likelihood of tobacco initiation. Consequently, tobacco consumption and prevalence are reduced via tax increases in low‐income groups by greater magnitudes than in higher‐income populations, resulting in a reduction in health inequities and tobacco use‐related poverty.28 Tobacco tax increases help reduce the impoverishing impact of tobacco use, help low‐income families get and stay out of poverty and help low‐ income individuals avoid disease and death associated with tobacco use.29,30 Tobacco taxes are the single most effective means of reducing and preventing tobacco use, including among disadvantaged populations.31

Tobacco tax increases can further reduce health inequities when a portion of the revenue generated is applied to targeted programs to help disadvantaged smokers quit and to keep youth tobacco‐free. Increasing tobacco taxes and dedicating a portion of the resulting new revenue to prevention and cessation services focused on disadvantaged populations can be an effective way to reduce initiation, increase cessation and reduce tobacco‐related disparities.32

Smoke‐free environments improve health equity

Comprehensive smoke‐free legislation can benefit people from all socioeconomic equally by increasing the number of places where people are protected from tobacco smoke. Smoke‐free laws are comprehensive when they prohibit smoking in all indoor public places and workplaces. These laws are the most effective way to protect all workers from secondhand smoke exposure in the workplace.33 They can also reduce the social acceptability of smoking, which can motivate smokers to quit and reduce tobacco initiation among youth.34 Although great progress has been made in creating smoke‐free environments in recent years, several groups‐‐particularly hospitality workers in waterpipe establishments and workers who clean hotel/motel guest rooms‐‐are not adequately protected by smoke‐free laws. These workers are not second‐class citizens and they deserve full protection from the harmful effects of secondhand smoke.

A comprehensive tobacco reduction strategy

In order to best support the disadvantaged members of society and reduce health inequities, tobacco reduction must be a government priority. We cannot ignore the strong and growing connection between tobacco use and health equity that exists in our province. The Alberta Tobacco Reduction Strategy must be fully funded and fully implemented with effective policy and program measures to reduce tobacco‐related health inequities. The Alberta government cannot ignore the growing health disparity that continues to result from tobacco use in Alberta.

Policy Recommendations

  1. Increase tobacco taxes by at least $1.50 per pack to bring tobacco affordability levels in line with neighboring provinces and to help reduce health inequities among disadvantaged Albertans.
  2. Apply the proceeds of the tax increase to support tobacco reduction and prevention initiatives focusing on vulnerable populations.
  3. Fully fund and implement the Alberta Tobacco Reduction Strategy with a focus on reducing health inequities including:
    • Increase access to tobacco cessation treatment including no‐cost NRT combined with counselling 
    • Extend smoking bans to protect all employees including hospitality workers 
    • Actively enforce restrictions on tobacco sales to minors 
    • Provide targeted cessation and prevention programs that are culturally adapted 
    • Target at‐risk populations with effective programs and strategies

References

1. U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. Chapter 16. The Impact of Tobacco Use and Tobacco Measure on Poverty and Development. NIH Publication No. 16‐CA‐8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/index.html

2. Reid, Jessica L. et.al, Socio‐economic Status and Smoking in Canada, 1999‐2006: Has There Been Any Progress on Disparities in Tobacco Use?. Can J Public Health 2010;101(1):73‐78.

3. Canadian Institute for Health Information. Trends in Income‐Related Health Inequalities in Canada: Summary Report. Ottawa, ON: CIHI; 2015

4. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Summary measures of socioeconomic inequalities in health. Toronto, ON: Queen’s Printer for Ontario; 2013.

5. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014.Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

6. Reid, Jessica L. et.al, Socio‐economic Status and Smoking in Canada, 1999‐2006: Has There Been Any Progress on Disparities in Tobacco Use?. Can J Public Health 2010;101(1):73‐78.

7. Corsi DJ, Lear SA, Chow CK, Subramanian SV, Boyle MH, et al. (2013) Socioeconomic and Geographic Patterning of Smoking Behaviour in Canada: A Cross‐Sectional Multilevel Analysis. PLoS ONE 8(2): e57646. doi:10.1371/journal.pone.0057646

8. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Summary measures of socioeconomic inequalities in health. Toronto, ON: Queen’s Printer for Ontario; 2013.

9. Canadian Institute for Health Information. Trends in Income‐Related Health Inequalities in Canada: Summary Report. Ottawa, ON: CIHI; 2015.

10. Loring, Belinda. Tobacco and Inequities: Guidance for addressing inequities in tobacco related harm. World Health Organization. 2014

11. Canadian Institute for Health Information. Trends in Income‐Related Health Inequalities in Canada: Summary Report. Ottawa, ON: CIHI; 2015.

12. Loring, Belinda. Tobacco and Inequities: Guidance for addressing inequities in tobacco related harm. World Health Organization. 2014

13. Corsi DJ, Lear SA, Chow CK, Subramanian SV, Boyle MH, et al. (2013) Socioeconomic and Geographic Patterning of Smoking Behaviour in Canada: A Cross‐Sectional Multilevel Analysis. PLoS ONE 8(2): e57646. doi:10.1371/journal.pone.0057646

14. Canadian Institute for Health Information. Trends in Income‐Related Health Inequalities in Canada: Summary Report. Ottawa, ON: CIHI; 2015.

15. Loring, Belinda. Tobacco and Inequities: Guidance for addressing inequities in tobacco related harm. World Health Organization. 2014

16. Reid, Jessica L. et.al,. Socio‐economic Status and Smoking in Canada, 1999‐2006: Has There Been Any Progress on Disparities in Tobacco Use?. Can J Public Health 2010;101(1):73‐78.

17. Canadian Institute for Health Information. Trends in Income‐Related Health Inequalities in Canada: Summary Report. Ottawa, ON: CIHI; 2015.

18. Loring, Belinda. Tobacco and Inequities: Guidance for addressing inequities in tobacco related harm. World Health Organization. 2014

19. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

20. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

21. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

22. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014.Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

23. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

24. World Health Organization. Best Practices in WHO Technical Manual on Tobacco Tax Administration. 2011. http://www.who.int/tobacco/publications/en_tfi_tob_tax_chapter5.pdf?ua=1

25. Canadian Coalition for Action on Tobacco. A Win‐Win: Enhancing Public Health and Public Revenue Recommendations to Increase Tobacco Taxes A Submission to the Hon. Ralph Goodale, P.C., M.P. Minister of Finance. Toronto, Ontario, 2004. http://www.smoke‐free.ca/pdf_1/2004taxreport.pdf

26. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

27. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

28. World Health Organization. Guidelines for Implementation of Article 6 of the WHO FCTC: Price and tax measures to reduce demand for tobacco. Framework Convention on Tobacco Control.

29. World Health Organization. Mpower: WHO Report on the Global Tobacco Epidemic, 2008. http://www.who.int/tobacco/mpower/en/

30. World Health Organization. The Economic and Health Benefits of Tobacco Taxation. Framework Convention on Tobacco Control. http://apps.who.int/iris/bitstream/10665/179423/1/WHO_NMH_PND_15.6_eng.pdf?ua=1&ua=1

31. U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. Chapter 16. The Impact of Tobacco Use and Tobacco Measure on Poverty and Development. NIH Publication No. 16‐CA‐8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. https://cancercontrol.cancer.gov/brp/tcrb/monographs/21/index.html

32. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

33. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.

34. Centers for Disease Control and Prevention. Best Practices User Guide: Health Equity in Tobacco Prevention and Control. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015.