Author: Loren Kock, PhD student, Tobacco and Alcohol Research Group

Smoking cigarettes remains a leading cause of preventable death and disease in many high-income countries. Most of these harms fall disproportionately upon socioeconomically disadvantaged individuals who generally have greater difficulty in quitting and remaining abstinent. In increasingly resource constrained health systems, what role does behavioural support that is tailored to an individual’s socioeconomic position (SEP) play in helping smokers quit and stay quit?

Reducing health inequalities, which includes access and provision of health-care services, has been included as one of the UN’s sustainable development goals (SDG 10). Given that smoking is estimated to kill almost 8 million people a year and largely falls along a socioeconomic gradient, acting to prevent uptake of smoking and to help existing smokers quit is an essential part of this goal. Alongside other interventions and policies, the WHO’s ‘MPOWER’ package of measures to reduce the prevalence of smoking worldwide, provision of behavioural support to individuals trying to quit smoking is widely thought to be an effective approach. An advantage of these interventions is that health providers can be flexible in their delivery; support can be delivered in-person or over the phone, via digital media or through the use of financial incentives.

To tailor or not to tailor?

Even with the best support, most people relapse to smoking within the first month of quitting. Interventions that are tailored to smokers from disadvantaged groups stem from the knowledge that these individuals have greater difficulty in quitting and remaining abstinent than do those from more affluent groups. This is largely due to issues such as financial stress, absence of social support, addiction, lower confidence, stress, scarce life opportunities and less interest in the harms related to smoking. Because they don’t specifically address these barriers, it is generally thought non-tailored interventions are generally less effective among disadvantaged groups and may therefore be exacerbating existing inequalities. Compared with interventions that have no specific demographic target (non-tailored), interventions that are tailored to address these socioeconomic barriers (SEP-tailored) could, at least in theory, be more successful.

Our study published in the Lancet Public Health sought to tease out how much more effective, if at all, SEP-tailoring was for helping socioeconomically disadvantaged smokers quit.

Is SEP-tailoring more effective?

Our analysis of long-term (6 month) smoking cessation among disadvantaged participants from 42 randomised controlled trials revealed that individual-level behavioural support, regardless of whether or not it is tailored, can assist disadvantaged smokers with quitting. As aforementioned, tailored approaches specifically are expected to have an important role in reducing health inequalities by addressing some of the needs specific to disadvantaged smokers. However, further analysis revealed that when compared with not tailoring, SEP-tailoring was no more effective.

Quitting is hard
These results highlight the challenges that disadvantaged smokers face when making a quit attempt. It’s likely that behavioural support is effective in the short term, but the benefits wear off or disappear entirely when weighed against the circumstances and stresses that a recently quit ex-smoker faces every day. Dealing with the cravings and withdrawals associated with abruptly coming off the highly dependence-inducing nicotine from cigarettes, while also having to face unstable employment, low income, poorer housing conditions and general lack of support makes it much more likely that a disadvantaged ex-smoker will find themselves returning to smoking. It may be that even when tailored behavioural support attempts to adjust for SEP, it isn’t quite enough when weighed against these life circumstances. However, although no more effective than non-tailored approaches, tailoring is still an effective method; our analysis estimated that all types of behavioural support can improve quit rates by over 50%.

Doing more, and better

These findings don’t imply that tailored approaches should be abandoned. Instead, they should be a call to action for improved, multifaceted approaches at the individual, community, and population level that recognise the wider context of socioeconomically disadvantaged smokers. Sometimes complex problems require complex solutions!

Read the paper: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30220-8/fulltext

Since their arrival in the UK in 2010/11, electronic cigarettes (e-cigarettes or vapes) have rapidly become the most popular aid to help people quit smoking. With evidence continuing to grow showing that vaping 1) poses a small fraction of the risks of smoking and 2) improves smoking quit success, Public Health England have restated that smokers who are struggling to quit should ‘try switching to an e-cigarette’ along with seeking help by trained specialists. But what does this mean for existing inequalities in smoking?

Following a steady decline over the past decade, 15% of the population in England are estimated to currently smoke. However, smoking rates fall along a social gradient, with one in four people from disadvantaged socio-economic groups smoking, compared with one in ten from more affluent groups. This means that a disproportionate number of the ~78,000 deaths and the ~485,000 hospital admissions caused by smoking in England each year fall upon the disadvantaged.

Given their popularity (used by >30% of smokers making a quit attempt) and generally lower cost compared with cigarettes, e-cigarettes have potential to help reduce inequalities in smoking cessation. However, a concern during the early period in which e-cigarettes first arrived on the UK market was that they were more popular with better off smokers. If the devices boost quit success, which appears to be the case, then these differences in use across the social gradient could potentially lead to disadvantaged smokers being left behind, thus worsening the existing inequalities.

Keeping up with change

Since their creation in 2003 by a Chinese pharmacist Hon Lik, e-cigarettes have continued to evolve with novel designs and more effective nicotine delivery systems being rolled out each year. The Smoking Toolkit Study (STS), set up by the Tobacco and Alcohol Research Group at UCL to monitor population trends in smoking in England, is one way that researchers and policy makers can keep up with this ever-changing landscape of e-cigarette use and assess whether they promote or detract from reducing smoking rates.

Using STS data from 2014 to 2017, our recent research published in the journal Addiction was the first of kind to look at the use of e-cigarettes by different socio-economic groups at the population level. Our study analysed data from over 81,000 adults in England, including 16,000 past-year smokers, 5,300 smokers making a quit attempt and 13,500 long-term ex-smokers. E-cigarette use in each group was assessed using participant social grade (based on occupation) or housing status as key indicators of socio-economic position.

Narrowing differences among smokers

Our analysis indicated that in the three years from 2014 to 2016, disadvantaged smokers were around half as likely to use e-cigarettes. However, by 2017 this difference was no longer evident. Similarly, there were no differences in e-cigarette use by smokers making a quit attempt. Should this absence of difference between socioeconomic groups remain going forward then it is unlikely that the use of e-cigarettes among smokers and quit attempters will have a persistent impact on inequalities. However, it will be important to investigate whether there are socio-economic differences in the success of quit attempts with e-cigarettes, something which researchers in our group have been looking into.

Greater e-cigarette use among disadvantaged ex-smokers

Our research also showed a different pattern among smokers who had been quit for over a year, with disadvantaged ex-smokers more than twice as likely to use an e-cigarette. This could have important implications, and really depends on whether e-cigarettes prevent ex-smokers from relapsing back into smoking tobacco. If that were true (unfortunately there isn’t much research on this yet) then e-cigarette use would protect more disadvantaged smokers from slipping back into smoking and act to reduce inequalities; an equity-positive effect.

The wider picture

Inequalities in smoking are driven by a complex and nuanced system acting at the population, community and individual level. Reducing disparity requires action at all levels such as tobacco taxes, public health media and education campaigns and individual specialist support that targets the neurobiological and motivational components of nicotine addiction that dependent smokers struggle with. E-cigarettes are not a magic wand for quitting smoking. Rather, given their popularity and similar effectiveness to other forms of nicotine replacement therapy, they are part of a toolbox of interventions that are contributing to the continuing decline in smoking in the UK. If they are available, affordable and able to deliver nicotine effectively without the loss of social identity that some smokers subscribe to, e-cigarettes may also help redress the persistent inequalities in smoking.

Loren Kock (@loren_kock.) is a Cancer Research UK funded PhD student in Epidemiology and Public health, working within the UCL Tobacco and Alcohol Research Group. His research focusses on how e-cigarettes and other smoking cessation interventions impact on socio-economic inequalities in smoking cessation.