Although smoking prevalence has decreased globally in the last decade, smoking is still the largest cause of preventable disease and premature death worldwide. In countries that have achieved lower smoking rates overall, disparities within the population remain. Populations with lower socioeconomic status (SES indicators) have higher smoking prevalence than those with higher SES indicators. Furthermore, smokers in the lower end of the socioeconomic scale have poorer health outcomes and die years earlier compared to their counterparts in the higher end of the socioeconomic spectrum.
Moderator David T. Sweanor J.D. pointed out the higher smoking rates among the most disadvantaged populations, such as people with mental health issues or low income and called the panel to elaborate on the issue and share their experience.
Tobacco use control and vaping in the USA face a strong opposition by the federal government and federal agencies, such as the CDCs and the FDA, and even by public health organizations which are federally funded, along with several tobacco control organizations that are very powerful and wealthy, Professor Helen Redmond said, starting her intervention. All the above parties are still very much weighted towards absolute abstinence and cessation of tobacco use, which is a very difficult proposition for the more vulnerable populations, she stressed. These agencies and stakeholders created a panic about the so called “teen vaping epidemic”, Prof. Redmond said, something that has never even existed in the USA.
Unfortunately, she commented, the harm reduction community in the USA also is not aboard for tobacco harm reduction. They believe in harm reduction for every other drug, but when it comes to nicotine, most pro-harm reduction organizations are not pushing for safer nicotine products.
Those are all obstacles to working with vulnerable populations, and as Prof. Redmond said, it seems that the USA government doesn’t care if people from vulnerable populations die from smoking-related diseases and added that they have a long history of not caring about diseases that afflict the most disadvantaged (e.g., AIDS), the most recent example being the COVID-19 pandemic. We have to confront the reality that the most vulnerable people do not count for the government, the speaker said and raised the question as to how to make the government care.
The teen vaping epidemic panic is now decreasing, the speaker noted and added that this is partly due to the irrefutable evidence that e-cigarettes are vastly safer than smoking and that millions of people around the world have used vaping to quit smoking. With that happening, she said, the space is hopefully opening in the USA to focus on the people who really need it.
According to Prof. Redmond, there are three things that we must target:
Firstly, putting an end to the contradictive attitude of the harm reduction community, who support overdose prevention centers and hand out sterile syringes but are opposed to vaping; hopefully, she said, more and more harm reduction-based organizations will embrace tobacco harm reduction.
Secondly, changing the media coverage, as it has been biased for many years, with “outright lies and exaggerations” ―the speaker said― although this is starting to diminish. Prof. Redmond pointed out that more people are opposing “junk science” and exaggerated claims, which is partly due to the authorization of e-cigarettes by the FDA; however, the Agency shows a contradictive attitude, confusing the public and losing its trust.
Thirdly, people who smoke are highly stigmatized and discriminated against, and more stories in the media are needed that show people who make the switch and how their lives have improved.
We need more activism for the right to access to these life-saving products and for the notion “nothing about us without us”, Prof. Redmond concluded. FDA has to move more quickly towards the right direction, she stressed.
Dr. Peter Harper presented the epidemics of the disparities in tobacco use prevalence, focusing on the UK. 22.3% of the global population used tobacco in 2022, which is translated to almost 1 billion cigarette smokers (962 million). Among the global population, 36.7% of men used tobacco, vs. 7.8% of women. This difference between the two sexes varies greatly by country: in some countries, women almost don’t smoke (e.g., Indonesia), meaning almost 100% of smoking in those countries is a men’s habit.
In the UK, the proportion of current smokers continued to decrease for several decades, Dr. Harper said, from almost 50% in 1974 to 14.1% in 2020. According to 2020 data, smoking prevalence is marginally higher among men (15.5%) vs. women (12.1%); it is highest among those between 25 to 34 years (18.3%); and it is highest in Scotland (16.0%) and lowest in Northern Ireland (13.2%). Current e-cigarette use in Great Britain was 3.8% daily and 2.6% occasionally in 2020; it has increased from the 3.7% in 2014, when reporting began.
Dr. Harper pointed out that we need to stop looking at the population as a whole and start looking at different groups of society and geographical areas. Based on this categorization and data from 2017, he presented the following disparities:
By marital status: married adults are the least likely to smoke (9%), whereas those that are single or cohabiting are the most likely to smoke (+20%, similar to the overall prevalence in 2010).
By socioeconomic status: those with Managerial & Professional occupations are the least likely to smoke (10%), whereas those with routine and manual occupations are the most likely to smoke (25%, similar to the overall prevalence in 2004).
By educational qualifications: those with a degree are the least likely to smoke (7%), whereas those with no qualification are the most likely to smoke (29%, similar to the overall prevalence in 1992).
By employment status: the inactive (retired and those having no intention to working) are the least likely to smoke (12%), whereas the unemployed are the most likely to smoke (29%, similar to the overall prevalence in 1992).
By locality: people living in Rushcliffe and Richmond upon Thames are the least likely to smoke (4% and 6%), whereas those living in Kingston upon Hull and Lincoln are the most likely to smoke (26%).
Overall, UK smoking prevalence (16% in 2016) was 2 percentage points lower than the OECD average of 18%. But some groups in society are worse, with up to 29% smoking prevalence, similar to that in countries with the highest daily smoking level and therefore we need to focus our attention on these groups.
Dr. Harper concluded his presentation by stating that he feels very proud of what health prevention in the UK has achieved, adding that it still has a long way to go. The factors that tend to lead to higher smoking rates are often combined and compound the risk. To achieve health equity in tobacco we must look at our approach to smoking, he said, and ensure that we have the right resources and approach to reduce smoking in groups with disproportionately higher smoking rates.
Dr. Rafael R. Castillo (Philippines) begun his speech by presenting the example of a car driver of low income ($20 a day) who spends 8-10% of his salary to buy cigarettes, to point out the disparities that exist due to socioeconomic and educational factors, and among and within racial and ethnic groups, something that is especially true in countries that are multicultural.
Dr. Castillo then drew the attention on the hidden truth that lies underneath the prevalence rates. For example, in the USA in a 50-year period, there has been a very remarkable reduction in the prevalence of smoking, from over 40% in 1965 to about 15% in 2015. However, in terms of reduction of the actual number of smokers, the difference is not that big (from around 45 million to about 40 million).
According to the 2015 Global Adult Tobacco Survey (GATS), Dr. Castillo said, 7 in 10 Filipino smokers would like to quit tobacco, but only 4% of those who smoked in the past 12 months reported success in fully quitting the deadly habit. Although sin taxes seemed at first to be the answer to the problem, Dr. Castillo commented, it soon appeared that despite the large amount of taxes collected by the government, this measure failed in achieving tobacco control.
Finally, another form of disparity is related to misappreciation of the risk-benefit perception, for example the perceptions about the introduction of alternative tobacco products in order to reduce morbidity and mortality among smokers unwilling or unable to quit. There is an amplification and an exaggeration of the risk of addicting a whole new generation to alternative tobacco products, Dr. Castillo said, completely neglecting the millions who are already currently smoking and who are certainly going to develop life-threatening complications.
Professor Solomon T. Rataemane gave some interesting facts about the situation in South Africa. Being a psychiatrist, he remarked that many patients in the psychiatric wards smoke, and if they are not given cigarettes, they become aggressive and violent. The situation in South Africa, a country with a population of about 65 million people, is very similar to that in a number of sub-Saharan African countries, Prof. Rataemane said. Every information that existed so far about smoking rates has been mainly anecdotal, until last year, when a group in Cape Town decided to do a study about tobacco use rates as during the lockdown due to COVID-19, the government imposed a ban on cigarettes and alcoholic products sales. As to the results, we do not know whether the ban helped, but we do know that it exposed the population to illicit cigarettes, he said. The country has the so called “Drug Master Plan”, which for the past 15 years focused on alcohol and hard drugs; only the past 5-8 years did it bring in tobacco. The concept of harm reduction has been an issue, the speaker said, as many people consider that it means that smokers should be assisted to continue their habit.
Prof. Rataemane then presented the Global Adult Tobacco Survey (GATS) study, conducted in 2021, which zoomed in adult tobacco use and examined the existence and effectiveness of the following measures: monitoring of tobacco use and prevention policies, protecting people from tobacco smoke, offering help to quit tobacco use, warning about dangers of tobacco, enforcing bans on tobacco advertising, promotion and sponsorship, and raising taxes on tobacco. The study had a robust methodology and it included information on respondents’ background characteristics, with a total of 7245 households surveyed, and a total of 6311 interviews completed (overall response rate of 91.5%).
Overall, 29.4% (12.7 million adults) currently used tobacco products (41.7% of men, and 17.9% of women). 25.8% (11.1 million adults) currently smoked tobacco (41.2% of men, and 11.5% of women), whereas 4.3% (1.8 million adults) currently used smokeless (mainly chewed) tobacco (1.1% of men, and 7.2% of women).
In terms of smoking cessation, 65.7% of current smokers planned to or were thinking about quitting smoking, 40.5% made a quit attempt in the past 12 months, and 42.9% of smokers who visited a healthcare provider in the past 12 months were advised to quit smoking. The problem is that there are no smoking cessation clinics in the public sector.
Despite the ban on indoors smoking, 11.2% of adults who worked indoors (1.2 million adults) were exposed to tobacco smoke in enclosed areas at their workplace, 18.0% of adults (7.7 million adults) were exposed to tobacco smoke inside their homes, and 10.8% of adults (1.1 million adults) were exposed to tobacco smoke when visiting restaurants.
In terms of the economics of smoking, the median monthly expenditure on manufactured cigarettes was 263.1 South African Rand (about 15 euros). This kind of spending means that people have less money to eat, Prof. Rataemane said, which is obviously problematic and leads the poor and the unemployed to purchase cheaper illicit cigarettes.
The study also examined the information given in the media about smoking. 30.5% of adults noticed anti-cigarette smoking information on the television or radio, but on the other hand, 22.3% of adults referred tobacco products advertising or promotions in stores where tobacco is sold, and 29.9% of adults referred other tobacco advertisements, promotions, or sporting event sponsorship. Prof. Rataemane underlined that many of the adverts/promotions did not include warning about dangers of smoking.
Concluding the study presentation with data on attitudes and perceptions, Prof. Rataemane said that 92.9% of adults believed smoking causes serious illness, 92.9% of adults believed breathing other peoples’ smoke causes serious illness in non-smokers, 88.4% support ban on smoking in indoor workplaces and public places, and 73.0% of adults support increasing taxes on tobacco products (although this last measure has been proven controversial).