The Background

About 8m (2016) people, some 15% of the population still smoke. This contrasts with the situation after the Second World War when over 80% of the population smoked. During the 1970s and 80s in particular there were considerable declines in smoking as the medical science behind the dangers of smoking became better known in the population.

But this obscures a key unpalatable truth, that most of the reduction in smoking has been as a result of the middle classes giving up smoking, rather than an across-the-board reduction which policy makers assume. Among people in lower socio-economic groups the decline has been much smaller.

Key Statistics for Smoking and Inequality

Indeed, there is a close link between cigarette smoking and social class. In 2017 studies by Action on Smoking and Health (ASH) showed that about 26% of adults in manual occupations smoked compared with 11% in managerial and professional occupations.

Additionally the working classes are more likely to be heavy smokers (defined as adults who smoke more than 20 cigarettes a day). A YouGov survey commissioned by ASH in 2019 found that 30% of current smokers in higher social groups AB smoked less than 6 cigarettes a day compared to 17% in lower social group E.

Additionally, 18% of smokers reported smoking 20-30 cigarettes a day in the lower socio-economic groups with only 5% smoking that number of cigarettes a day in the higher socio-economic groups. In other words, the higher the social class, the fewer the cigarettes smoked by smokers.

Higher smoking prevalence is associated with almost every indicator of deprivation or marginalisation in society compared to the population as a whole. For example, smoking is more common among the unemployed; people with mental health problems; people who live in social housing; people without qualifications, and people in contact with the social justice system.

How much health inequality is caused by smoking?

There have been various studies to try and identify this. Using the incidence of mortality in large datasets probably give the best results. For example, in a long term study of over 10,000 civil servants in London, smoking was found to account for around a third of the difference in death rates between the lowest and the highest socio economic groups over a period of 25 years. (1)

In an international study of deaths among men aged 35-70 which included data on 600,000 men, smoking was found to account for about half the difference in mortality between the top and bottom socio economic groups in England. (2)

In general, long term studies have found that around a third to a half of health inequalities are caused by smoking. For reference, of the other causes, about 30% of health inequalities are considered to come from obesity, with the final 20% or so being the result of alcohol and a variety of other causes relating to poverty.

Why does nobody seem to care?

Nearly all British government health institutions, such as the Dept. of Health and Social Care, the NHS, and quasi-government institutions such as Public Health England, and Health and Wellbeing boards run by local government, claim to put health inequalities at the heart of their work, and in many cases are legally obliged to do so. In practice, the phrase “health inequalities” is a euphemism for good intentions, but where little action is taken. Indeed, smoking cessation services (which have been delegated to local authorities) have been severely reduced in recent years due to constant budget cuts.

It is the case with many public health matters, that there is still a reliance by policy makers on “individual responsibility”, in other words, smoking among lower socio economic groups is the responsibility of those specific groups; as far as the health authorities are concerned it is a case of tut, tut, hands up, – nothing to do with me, mate! Or better still, blaming it on the cigarette companies.

But perhaps the really reason that officials are indifferent to the health inequalities of smoking is that cigarettes bring in some £12.5bn a year of taxation (incl. VAT) for central government, not an insignificant amount and roughly equivalent to the amount raised from stamp duty taxes.

Why should we care?

We should care because cigarettes cause some of the deadliest of all cancers and diseases, and it is an abomination that people suffer from these diseases and have shorter lifespans just because they were born into lower socio-economic groups. Smoking causes harm to every organ of the body, but as far as cancer is concerned the most relevant cancer is lung cancer, one of the most deadly of cancers. But it also causes some twelve other cancers, among them bowel, bladder, kidney, oesophageal and pancreatic cancer.

Who should take action?

Everybody should take action to lobby against these types of health inequalities, not just cancer campaigners like CancerWatch, but also groups campaigning for greater social justice such as the Child Poverty Action Group, food banks, trades unions representing lower paid workers, providers of social housing, politicians who campaign of behalf of lower income groups, not to mention other health charities. These groups and associations all have their part to play and CancerWatch will be encouraging them to play it.

The CancerWatch Team

Summer 2020

Notes:

Stringhini S, Sabia S, Shipley M et al. Association of socioeconomic position with health behaviors and mortality. JAMA 2010; 303(12):1159-1166
Jha P, Peto R, Zatonski W, et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. The Lancet 2006; 36: 367–370.