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28 November 2006
   
 

European Inequality in Health



Tobacco use entrenched in vulnerable groups across Europe ? October 2005 HELP : For a Life Without Tobacco Smoking Inequality in the EU Tobacco smoking among men and women in the EU is increasingly concentrated in the lower socio-economic groups. The prevelence and amount of smoking is considerably higher among men and women who have lower education, lower income and lower social class. In some vulnerable groups such as lone mothers and the unemployed there is even more of a sharp contrast as they smoke more often and in greater quantities. In many EU countries smoking is probably the largest single contributor to socio-economic inequalities in premature death, especially among men.The HELP campaign launched by the EU in spring this year aims at not only encouraging people to quit smoking but reducing the gap in smoking prevelence between higher and lower social groups. 1. Patterns and trends in smoking inequalities By the year 2000 smoking was more common in men in lower socio-economic groups in all EU countries. These inequalities in smoking were highest in the north of Europe, particularly in the United Kingdom, but although they were less pronounced in other parts of Europe, especially Italy and Spain, they are emerging among the younger generations. (1) A EU wide survey in 1998 showed that two thirds of all male smokers had incomes below the national median.(2) Even larger differences were seen in relation to education levels. In Finland in 2001 men from a lower educational background were 1.5 times more likely to smoke than men with higher levels of education.(3) Inequality among women smokers emerged or widened dramatically between 1985 and 2000. In the northern part of Europe including Ireland, the United Kingdom, the Netherlands, and Scandinavian countries inequalities became as large among women as among men. In the more southern countries smoking was more common among highly educated women in the 1980s but this pattern reversed and inequalities in smoking emerged, especially in Spain and Italy, as high-educated women quit.(4) A 1998 study in the United Kingdom shows that only 10% of women and 12% of men in the highest socio-economic group are smokers while 35% of women and 40% of men in the lowest group smoke. In countries with the longest history of smoking, especially in the north of Europe, it is probably the largest single cause of in morbidity and premature mortality. (5)Men from lower socio-economic groups have a much higher risk of dying from smoking-related diseases than men from upper groups. (6) And large inequalities in lung cancer deaths have been found in men in eight countries in both northern and southern Europe. (7) For example in England and Wales lung case death rates are four times higher among unskilled manual workers than among professionals and senior managers (8). In Poland in 1996 the risk of dying during middle age due to tobacco related diseases was 5% among people with higher education and nearly double at 9% among people with lower education level. As Eastern and Central European countries join the EU these health inequalities will become even more of a concern as citizens of less wealthy countries have poorer health and shorter life expectancy than those in Western Europe. 2. Influences on starting to smoke and quitting smoking Most persistent smokers start during adolescence. Adolescents with lower levels of education, poverty, and social disadvantage have a higher chance to start smoking and become addicted. Disadvantaged adolescents are more likely to start smoking because of: 1. Poor perceptions of smoking risk 2. Parental influences ? parents or sibling smoke 3. Poor resistance to peer pressure 4. Problems at home or school 5. Psychological problems. During adulthood men and women with low education, low income or living on social welfare have a higher chance of continuing smoking or of relapsing if they quit. (5) Less success at quitting is due to higher levels of nicotine addiction, increased psychosocial stress, lack of social support, perceived barriers such as weight gain, and lower confidence in the ability to quit. Men and women who have to face material and social deprivation have particularly difficulties in quitting smoking. People living in disadvantaged circumstances are more likely to use smoking as a coping mechanism. For many it is an important source of pleasure and coping by helping them to deal with stress, boredom, and poverty. In addition, in many disadvantaged communities smoking is the norm which makes it even more difficult for smokers to quit successfully. There is no established culture of quitting, little awareness of the methods available to aid smoking cessation and more distrust with the quality of services available. For example, pregnant women are less likely to quit smoking if they live in a low income community and/or their partner smokes. A British study showed that the chances of successfully quitting smoking was more than 60 per cent in professional pregnant women compared to less than 30 per cent in women who had never worked and 40 per cent in teenage mothers. (9) The same equally large inequalities were found in Sweden (10). In countries with the longest history of smoking it is often not due to a lack of knowledge or willingness to quit but difficulty in successful quitting. If they do try to quit men and women with lower socio-economic status are less successful than smokers in upper groups because they face more problems including higher nicotine dependence among smokers from lower groups. This may be due to the higher average number of cigarettes smoked and the earlier age of starting smoking. 3. Tobacco and poverty Tobacco increases poverty at both the individual household and national levels. For the poor money spent on tobacco is money not spent on basic, essential needs such as food, housing, education and healthcare. They spend a larger proportion of their income on tobacco than do richer households. Tobacco also contributes to the poverty of individuals and families since smokers are at a much higher risk of falling ill and dying prematurely of cancers, heart attacks, respiratory diseases or other tobacco-related diseases. Ill-health caused by tobacco is often the trigger for a downward slide into more extreme poverty. (11) At the national level countries suffer huge economic losses as a result of high health-care costs, as well as lost productivity due to tobacco-related illnesses and premature deaths. The overall annual cost of health care attributed to tobacco use has been estimated between 6% and 15% of total healthcare costs.(11) Premature deaths from tobacco can have an impact on national economies, robbing them of productive workers. Tobacco?s contributions to the economy through employment and government tax revenue are outweighed by its costs to households, to public health, to the environment and to national economics. 4. Conclusion ? Taking effective action to help smoking inequalities The WHO Framework Convention on Tobacco Control (FCTC), which came into force in February 2005 and has already been ratified by many countries in the EU identifies the key elements that countries around the world should implement to most effectively tackle smoking. The FCTC also recognises the importance of taking a socio-economic approach when developing and implementing these policies so that they address the different reasons why disadvantaged groups start to smoke and why they find it difficult to quit. Many tobacco control measures have the potential to reduce overall smoking prevalence and at the same time achieve the largest reductions among lower socio-economic groups. These include banning of advertisements, rising tobacco prices, work place interventions, free supply of cessation aids, and telephone help lines. The full potential for developing socio-economic-centred approaches to tobacco control across Europe has not been reached and in some countries there has only been limited action. However many members of the European Network of Smoking Prevention (ENSP) are now providing services that supplement mainstream services by: · Services that contact the smokers directly in their own environment- home care, hospital ward, community centre and work place · Provide easy town centre drop in centres that do not require registration and other formalities that are considered a barrier · Provide Quitlines that are confidential and anonymously accessed · Provide culturally and linguistically sensitive services that not only improve health but also restore the dignity of the service users. Given the widening of inequalities in smoking in recent years the future burden of smoking-related diseases may become increasingly more concentrated among men and women from lower socio-economic groups. Reaching these groups is essential to achieve a significant reduction in smoking. Without action smoking inequalities are likely to persist in future decades and may even widen. SOURCES : 1.Cavelars, A et al Educational differences in smoking : international comparison. British Medical Journal, 2000. Faggiano, F., E. Versino, and P Lemma. Decennial trends of social differentials in smoking habits in Italy. Cancer Causes and Control 2001 ; Fernandex, E., et al. widening socioeconomic inequalities in smoking cessation in Spain, 1987-1997 Journal of Epidemiology and Community Health 2001. 2. Huisman, M, AE Kunst, and JP Mackenbach. Education compared to income as predictors of smoking in 12 members states of the EU. Journal of Epidemiology and Community Health 2004. 3. Huisman, M, AE Kunst, and JP Mackenbach. Educational differences in smoking among men and women in 12 members states of the EU 2004 4. Giskes K et al., Trends in smoking inequalities in eight European countries.1985 ? 2000. 2004 5. EU Network on Intervention to Reduce Socio-Economic Inequalities in Health Socio Economic Inequalities in Smoking in the EU. September 2004 6. Poverty and Smoking and Tobacco Control in Developing Countries. Oxford University Press. 2000. 7. Mackenbach JP et al., Inequalities in lung cancer mortality by the educational level n 10 European populations. European Journal of Cancer 2004 8. Population Trends 1996 9. London Health Development Agency 2003 10. Moussa K, M Nilsson and P O Ostergren. Time trends in Sweden regarding socio-economic differences in smoking during pregnancy from 1982 ? 2000. 2004. 11. WHO Tobacco and Poverty ? A Vicious Circle 2004. ----------- The HELP - For a life without tobacco - campaign of the European Commission aims at convincing people not to start or to quit smoking with a TV-campaign in the 25 member states and different promotional activities. As part of the new anti-smoking campaign ?HELP ? For a life without tobacco? launched by the European Commission, regular press releases will be sent out (from April to November) to provide media with relevant health-related information in order to accompany, prolong and intensify the ?HELP? campaign measures. - ?The views expressed may not in any circumstances be regarded as stating an official position of the European Commission". - More detailed information with references to scientific papers can be obtained upon simple request. CONTACT: