Last updated: December 2016
Suggested citation: Greenhalgh, EM, Scollo, MM, & Pearce, M. 9.9 Are there inequalities in access to and use of treatment for smoking? In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-9-disadvantage/9-9-are-there-inequalities-in-access-to-and-usage-
Lower socio-economic status (SES) smokers tend to smoke more heavily, be more highly dependent on nicotine, and be less successful and confident in quitting.1-4 For this reason they may benefit from extended and/or more intensive cessation interventions. It is therefore important that governments ensure such treatments and services are affordable, accessible, and attractive to disadvantaged smokers. Despite their lower success rates, low-SES smokers report being just as likely to prioritise and attempt quitting as high-SES smokers.4
Telephone-based cessation information and counselling services, such as the Quitline, offer enormous potential for the delivery of low cost and high reach cessation interventions (See Chapter 7, Section 7.14 ). Disadvantaged groups may face additional barriers to using the Quitline, such as lacking access to a phone,5 and the cost of making the call from a mobile.6 Nonetheless, recent Victorian data show that low SES smokers were just as likely to call the Quitline in 2015 as high SES smokers, and were more likely to have visited the Quit website to obtain information about cessation (see Figure 9.9.1).4
Use of Quit website and Quitline in past 12 months among current smokers by SES, 2015
Source: Centre for Behavioural Research in Cancer 4
Further, although they may have lower success rates than higher SES smokers,7 quit rates among priority population callers to the Quitline suggest that the service is effective when used by high risk and underserved populations.8 In Australia, increased spending on (and therefore greater levels of public exposure to) antismoking campaigns appears to be as effective in prompting additional calls to the Quitline in lower, compared to higher, SES groups.9
Since February 2011, the Australian government has provided heavy subsidises of one 12-week course of nicotine patches per year with a prescription via the Pharmaceutical Benefits Scheme (PBS), with even greater subsidies for concession card holders.10 Indigenous Australians can access additional courses of NRT at low or no cost under the Closing the Gap scheme and/or via community organisations.11, 12 Mental health facilities and prisons—which are overrepresented by disadvantaged groups—also generally provide access to NRT.12 Bupropion (Zyban SR® and Prexaton ®) and varenicline (Champix®) have been available on Australia’s PBS since 2001 and 2008, respectively.
Figure 9.9.2 shows the number of concessional and non-concessional prescriptions filled for cessation medications under the PBS since 2001. There was a substantial increase in uptake of NRT, bupropion, and varenicline, both among concessional and general patients, when each of these medications was added to the PBS. Since 2014, more prescriptions have been provided to smokers with concession cards, with a substantially higher proportion of NRT prescription recipients being concessional. In 2015, 79% of all NRT prescriptions were for concession patients.
Annual total number of prescriptions for anti-smoking medications, Australia, January 2001 to September 2016: bupropion, varenicline, and NRT
Source: Pharmaceutical Benefits Scheme database statistics http://medicarestatistics.humanservices.gov.au/statistics/pbs_item.jsp
Other Australian data similarly shows high uptake of cessation medications among low-income groups. An analysis of data from the Australian National Drug Strategy Household Survey between 2001 and 2010 concluded that low-SES smokers use cessation support and services equally compared with high-SES smokers. Low-SES smokers were generally more likely to seek help from a doctor and to use prescription medication than high-SES smokers, which indicates their willingness to receive assistance with their quit attempts.13 Figure 9.9.3 presents data from wave eight (2010) of the International Tobacco Control Four-country Survey showing prescription medication use on the most recent quit attempt by annual household income. Those in the lowest income households were more likely than households of higher income to report using prescription stop-smoking medication.
Proportion of Australian smokers using prescription stop-smoking medications on their last quit attempt, among those who made quit attempts, 2010, by annual household income
Source: Data file of responses to eighth wave of the International Tobacco Control Four-country Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, Cancer Council Victoria, 2012
More recent Victorian data similarly shows that low- and mid-SES smokers who had tried to quit in the past year tended to be more likely than high-SES smokers to use cessation aids or support (see Figure 9.9.4). In particular, more low-SES smokers had used cessation medications and internet sites than mid- and high-SES smokers.
Proportion of Victorian smokers using pharmacotherapy (NRT, cessation medications, or e-cigarettes), behavioural support (health professional advice, internet sites, self-help materials, quitline, or a mobile app), both, or any pharmacotherapy or behavioural service during their last quit attempt by SES, 2015
Source: Centre for Behavioural Research in Cancer, 20164
Despite these encouraging findings, disadvantaged groups may still face barriers to accessing and using cessation medications. Even with subsidisation, the cost of pharmacotherapies may hinder their use among those on low incomes.14, 15 The cost and time associated with visiting a doctor to obtain a prescription may outweigh the benefits of subsidies for such smokers.14 Recent Victorian research found that low-SES smokers were equally likely to be aware that NRT is available on the PBS;4 however some groups, such as Indigenous Australians16 and clients of social and community services,15 may lack such awareness. Australian smokers may underrate the potential usefulness of cessation interventions and pharmacotherapies, and this is particularly true for smokers in low-income groups.17, 18 A qualitative study with Indigenous Australians found that some participants were skeptical and distrustful of pharmaceutical support for quitting, perceiving it as addictive and its use as evidence of poor willpower.19 Limited availability of cessation products in remote communities can also hinder use.20 US researchers found that very low-income smokers may also believe that cessation medications are dangerous.21
Targeted national smoking cessation services appear to reduce inequalities in smoking prevalence by achieving higher reach among disadvantaged smokers, compensating for their overall lower quit rates.22 An Australian study found that offering subsidised NRT increased engagement with the Quitline among low-income smokers, which promoted successful quitting.23
Adherence to pharmacotherapy (i.e., taking it as directed) increases the chances of cessation, however low-SES smokers are more likely to discontinue treatment early.24 A small Australian study found that among Indigenous Australians who had used cessation aids, none had completed the full course of treatment.19 A study of smokers using NRT in the general US community (i.e. NRT purchased over the counter rather than prescribed by their doctor) found that those with very low incomes and those of minority status were much more likely to discontinue NRT use if they had slipped up, if they suffered side effects, or if they felt that it was not helping with quitting.25
Similarly a study of smokers using cessation services in the UK (which included group program and one-to-one behavioural support, as well as the offer of pharmacotherapy) reported that at 52-week follow up, 14% of smokers of higher-SES had remained quit, compared to about 5% of smokers in the lowest socio-economic group. The researchers concluded treatment compliance was one of the factors relating to disparity in quitting success.26 Tobacco control interventions that increase support for quit attempts, enhance motivation and self-efficacy, and reduce other life stress may help to increase treatment compliance among low-SES groups.24
Data from the seventh wave of the International Tobacco Control Four-country Survey (between October 2008 and March 2009) showed that smokers of lower educational attainment were more likely than any other group to report being advised to quit smoking by their doctor. There was a slight increase from 2006 among smokers who had completed schooling, obtained a trade qualification or completed some university reporting being advised to quit (up from 51%, 52% and 48% respectively).
Proportion of smokers who could recall having been advised to quit by their doctor, Australia, 2008–09, by level of educational attainment
Source: Data file of responses to seventh wave of the International Tobacco Control Four-country Survey, provided to Merryn Pearce of the Tobacco Control Unit, Cancer Council Victoria, by T Partos and R Borland, Cancer Council Victoria, 2012
Nonetheless, there are some settings where disadvantaged smokers may be less likely to receive advice and support to quit. Smoking has traditionally been supported and encouraged in mental health and drug and alcohol settings (see Section 7.12 ). The normalisation of smoking among Indigenous communities, along with the high prevalence among healthcare workers, can similarly hinder the provision of cessation support (see Chapter 8 ). Encouraging and integrating tobacco cessation with such populations and settings may form an important part of reducing the disparities in smoking and health.
1. Hyland A, Borland R, Li Q, Yong HH, McNeill A, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006; 15 Suppl 3:iii83-94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16754952
2. Siahpush M, McNeill A, Borland R, and Fong GT. Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006; 15(suppl. 3):iii71–iii5. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii71
3. Kotz D and West R. Explaining the social gradient in smoking cessation: It's not in the trying, but in the succeeding. Tobacco Control, 2009; 18(1):43–6. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/1/43
4. Centre for Behavioural Research in Cancer. Quitting strategies used by current smokers and recent quitters: Findings from the 2015 Victorian smoking and health survey. Melbourne: Cancer Council Victoria, 2016.
5. Sheffer C, Brackman S, Lercara C, Cottoms N, Olson M, et al. When free is not for me: Confronting the barriers to use of free quitline telephone counseling for tobacco dependence. International Journal of Environmental Research and Public Health, 2015; 13(1). Available from: http://www.ncbi.nlm.nih.gov/pubmed/26703662
6. Bernstein SL, Rosner JM, and Toll B. Cell phone ownership and service plans among low-income smokers: The hidden cost of quitlines. Nicotine & Tobacco Research, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26920647
7. Varghese M, Sheffer C, Stitzer M, Landes R, Brackman SL, et al. Socioeconomic disparities in telephone-based treatment of tobacco dependence. American Journal of Public Health, 2014; 104(8):e76–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24922165
8. Kerkvliet JL and Fahrenwald NL. Tobacco quitline outcomes for priority populations. South Dakota Medicine, 2015; Spec No:63–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25985612
9. Siahpush M, Wakefield M, Spittal M, and Durkin S. Anti-smoking television advertising and socio-economic variations in calls to quitline. Journal of Epidemiology and Community Health, 2007; 61(4):298–301. Available from: http://jech.bmj.com/cgi/content/full/61/4/298
10. Australian Government, The extension of the listing of nicotine patches on the Pharmaceutical Benefits Scheme from 1 February 2011. Department of Health; 2013. Available from: http://www.pbs.gov.au/info/publication/factsheets/shared/Extension_of_the_listing_of_nicotine_patches
11. Ivers R, Anti-tobacco programs for Aboriginal and Torres Strait Islander people. Produced for the Closing The Gap clearinghouse. Canberra: Australian Institute of Health and Welfare & Melbourne: Australian Institute of Family Studies; 2011. Available from: http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2011/ctgc-rs04.pdf
12. Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, et al. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug and Alcohol Review, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26661119
13. Clare P, Slade T, Courtney RJ, Martire KA, and Mattick RP. The use of smoking cessation and quit support services by socioeconomic status over 10 years of the National Drug Strategy Household Survey. Nicotine & Tobacco Research, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25320110
14. Glover M, Fraser T, and Nosa V. Views of low socio-economic smokers: What will help them to quit? Journal of Smoking Cessation, 2012; 7(1):41–6. Available from: https://www.cambridge.org/core/article/views-of-low-socio-economic-smokers-what-will-help-m-to-quit/A24E4B2FC2F9078B510D5545E7F14700
15. Bryant J, Bonevski B, Paul C, O'Brien J, and Oakes W. Developing cessation interventions for the social and community service setting: A qualitative study of barriers to quitting among disadvantaged Australian smokers. BMC Public Health, 2011; 11:493. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21699730
16. Gould GS, Munn J, Watters T, McEwen A, and Clough AR. Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait islanders: A systematic review and meta-ethnography. Nicotine & Tobacco Research, 2013; 15(5):863–74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23042985
17. Borland R, Pigott R, Rintoul D, Shore S, and Young S. Barriers to access of smoking cessation programs, nicotine replacement therapy and other pharmacotherapies for the general Australian population and at−risk population groups. Final report to Australian government department of health and ageing. Literature Review vol 1, 1 Canberra: VicHealth Centre for Tobacco Control, Cancer Council Victoria, 2002.
18. Carter S, Borland R, and Chapman C. Finding the strength to kill your best friend–smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf
19. Bond C, Brough M, Spurling G, and Hayman N. ‘It had to be my choice’ Indigenous smoking cessation and negotiations of risk, resistance and resilience. Health, Risk & Society, 2012; 14(6):565–81. Available from: http://dx.doi.org/10.1080/13698575.2012.701274
20. Johnston V and Thomas DP. What works in Indigenous tobacco control? The perceptions of remote Indigenous community members and health staff. Health Promotion Journal of Australia, 2010; 21(1):45–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20406152
21. Christiansen B, Reeder K, Hill M, Baker T, and Fiore M. Barriers to effective tobacco-dependence treatment for the very poor. Journal of Studies on Alcohol and Drugs, 2012; 73(6):874–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23036204
22. Brown T, Platt S, and Amos A. Equity impact of population-level interventions and policies to reduce smoking in adults: A systematic review. Drug and Alcohol Dependence, 2014; 138:7–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24674707
23. Miller CL and Sedivy V. Using a quitline plus low-cost nicotine replacement therapy to help disadvantaged smokers to quit. Tobacco Control, 2009; 18(2):144–9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/18/2/144
24. Hiscock R, Bauld L, Amos A, Fidler JA, and Munafo M. Socioeconomic status and smoking: A review. Annals of the New York Academy of Sciences, 2012; 1248:107–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22092035
25. Burns E and Levinson A. Discontinuation of nicotine replacement therapy among smoking-cessation attempters. American Journal of Preventive Medicine, 2008; 34(3):212–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18312809
26. Hiscock R, Judge K, and Bauld L. Social inequalities in quitting smoking: What factors mediate the relationship between socioeconomic position and smoking cessation? Journal of Public Health, 2010; 33(1):39–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21178184