Ways to reduce social inequalities in smoking

During the 14^th Tab'Actu meeting, Romain Guignard from the Public Health France agency recalled why the least privileged social categories are more exposed to smoking. He presented the responses of Public Health France to this situation and outlined some avenues for reducing smoking in this population.

The survey conducted by Santé Publique France in 2022 on the latest smoking trends indicated that tobacco use is continuing at a high level in France. It remains particularly worrying in the least advantaged socio-professional categories, where the gap in smoking prevalence with advantaged populations has generally widened over the last few decades.

Speaker at the 14^th Tab'Actu meeting, organized in Villers-les-Nancy on October 12, 2023, Romain Guignard, scientific expertise officer at Santé Publique France, painted a picture of this phenomenon and the possible ways to remedy it.

Significant difference in smoking prevalence between social groups

After increasing sharply between 2000 and 2016, social inequalities in smoking had experienced a period of decline. The gap in smoking prevalence has widened again since 2019. It now shows a difference of 14 points between graduates and those with a level of education below the baccalaureate, and 12 points between the highest and lowest incomes.[1]The peak of smoking prevalence is reached among the unemployed (40 %). youth smoking is significantly reduced, going from 32.4 % of daily smokers at 17 years old in 2014 to 15.6 % in 2022[2], but significant gaps are observed between young people depending on their educational background.

The scientific literature indicates that the poorest smokers try as much as others to quit smoking, but succeed less easily. While the intention to quit smoking increases when smokers encounter financial difficulties, smokers from disadvantaged backgrounds have more difficulty starting the quit process and experience more failures. The risks associated with tobacco are also less well perceived among disadvantaged populations, who also plan less for the future. One hypothesis suggests a stronger nicotine dependence among disadvantaged populations, who are more exposed to various stresses (arduous work, living conditions, family history). Exposure to passive smoking, more frequent in disadvantaged households, and the entrenchment of the smoking norm also increase the risk for young people of starting to smoke and becoming smokers.

Motivations and barriers to quitting smoking among disadvantaged groups

A qualitative study conducted by Santé Publique France and Kantar between November 2020 and February 2021 explored the motivations and barriers to quitting smoking in lower and intermediate socio-professional categories. The main motivations for quitting were health preservation, the cost of tobacco (after the €10 packet threshold) and freedom from an addiction. Among the barriers, fear of the consequences of quitting (withdrawal, irritability, weight gain), as well as fear of failure, appeared to be paramount. The loss of what is perceived as a pleasure and a crutch to cope with stress, as well as the impression of losing part of one's sociability, or even one's identity, were also expressed. The feeling of being alone when faced with smoking, lack of knowledge of treatments and quitting aids and a certain distrust of institutions and health messages accentuate these barriers to quitting.

Tools to reduce social inequalities in tobacco

Reducing smoking among the most vulnerable populations is a public health priority. Several avenues have been outlined to achieve this. The aim is to better support these populations, to bring them closer to health professionals and to highlight the value of validated cessation aids. Certain principles are now accepted:

• offer smoking cessation support services as close as possible to these populations;
• adopt a proactive approach, by regularly offering help to stop smoking;
• rely on solid scientific foundations and popularize them;
• involve target audiences in the design of interventions;
• remove financial barriers, in particular by providing information on the terms of reimbursement for nicotine treatments.

On the ground, social marketing operations such as No Tobacco Month offer the advantage of being both relayed by the media and by local networks. Tools that have proven their effectiveness with modest smokers, such as the English site StopAdvisor, would benefit from being available in a French version.[3]. Line 3989, the Tabac Info Service website and application also provide very accessible ways to get in touch with tobacco specialists.

Finally, targeted communication campaigns featuring testimonies from people on low incomes, such as that deployed by Santé Publique France in 2022 in the form of videos and posters, seem more suited to disadvantaged populations than general information campaigns.

Keywords: social inequalities, disadvantaged categories, Public Health France, No Tobacco Month

©Tobacco Free Generation

M.F.

[1] Pasquereau A, Andler R, Guignard R, Soullier N, Beck F, Nguyen-Thanh V. Prevalence of smoking and vaping in metropolitan France in 2022 among 18-75 year-olds. Bull Epidemiol Hebd. 2023;(9-10):152-8.

[2] OFDT, Drugs at 17, Analysis of the ESCAPAD 2022 survey, Trends No. 155, March 2023, 8 p.

[3] Arwidson P, Guignard R, Nguyen-Thanh V. Design and evaluation of a smoking cessation intervention aimed at reducing health inequalities. The example of the StopAdvisor website in Great Britain. Bull Epidemiol Weekly. 2016;(16-17):320-5.