A photograph of a man sitting on a bench, smoking

This is the second instalment of our series on health inequalities, where we explore the unfair and avoidable differences in cancer incidence and outcomes across society. Our first post looked at what health inequalities are, and how we can reduce them.

In this piece, we investigate what’s behind differences in smoking with Jamie Hartmann-Boyce, Associate Professor in evidence-based medicine at the University of Oxford.

Smoking causes cancer, but what causes smoking?

The link between tobacco and cancer is very well established. Decades of research show that smoking increases the risk of at least 15 different types of cancer. And it’s not ‘news’ anymore – 94% of UK adults recognise smoking as a risk factor for cancer when prompted.*

We know that smoking is more common in some population groups than others. But if most people know that smoking is bad for them, why is this the case?

This question is fundamental to understanding inequalities in cancer, and the answer is very complex.

Around 4 in 10 cancer cases in the UK are preventable, through things like not smoking and keeping a healthy weight.

So, why do we continue putting our health at risk, if we know how to be healthy?

For people who smoke it’s not as simple as avoiding cigarettes because they’re unhealthy and costly. Some people are more likely to try a cigarette than others, and often factors outside of our control can make all the difference. For many, that first puff paves the way to long-lasting addiction.

Groups at higher risk

Smoking is the biggest preventable cause of cancer. And because some groups are more likely to smoke and find it harder to stop, smoking is also the single biggest driver of cancer inequalities.

We spoke to Professor Jamie Hartmann-Boyce about the groups most at risk.

“We know that there are certain groups in the population who are more likely to smoke. Those include people in deprived areas, people with mental health conditions, and the LGBTQ+ community.” says Hartmann-Boyce.

“People from less advantaged groups tend to be more heavily addicted. They tend to start smoking earlier, and therefore there’s more for them to overcome when they’re trying to quit smoking,” adds Hartmann-Boyce. “We also know that there is some disparity in access to medications and behavioural support, which are and should be offered for free.”

For example, stop smoking services, which provide medications and behavioural support, aren’t currently available in all areas of the UK, despite these services offering the best chance of success for people looking to quit.

But differences in the availability of stop smoking support are only part of the picture. To understand disparities in smoking, we also need to look at factors that determine how likely someone is to smoke.

Why are some people more likely to smoke?

The factors that underly health and health behaviours are many and complex. These include the pressures and opportunities someone has faced over the course of their life, as well as their current circumstances, collectively known as the ‘wider determinants of health’.

“There are a number of forces at play, and I think it’s important to note that most people who start smoking do so as children,” says Hartmann-Boyce. “Cigarettes have been engineered over time to be as addictive as possible, so if you start using them as a younger person, by the time you are older you are often so addicted that it is incredibly difficult to quit, especially without the right support.”

Children’s exposure and access to tobacco is determined by both environmental and social factors. And one of the most powerful determinants is the family environment – in particular, parental smoking.

“If your parents smoke you are much more likely to smoke and continue to smoke, and so that creates a cycle,” says Hartmann-Boyce. “Someone born in one of the least deprived areas in the UK is going to be much more protected from all the things that are going to make a kid want to try a cigarette, compared to a kid living in one of the most deprived areas.”

What might this look like in real life? A child living in a more deprived area might live with someone who smokes, grow up near to more shops that sell cigarettes, be exposed to more tobacco imagery in the media, and have friends that smoke.

Seeing something regularly can make that thing seem more normal and less risky. Even if children are told that cigarettes are health risks, they’re less likely to avoid them if they see them in media and for sale where they live, or see family and friends, who have been subject to the same pressures, using them.

The tobacco industry

We can’t choose the circumstances we’re born into, but it’s not all a game of chance.

Where industry is involved, public health can get pushed aside for profit. This is unfortunately the case for lots of cancer causes, but especially for tobacco.

The industry has encouraged smoking through various means, including advertising, ease of access, and visibility of products in shops.

That’s why national policy measures that restrict tobacco marketing have been so effective.

Hartmann-Boyce says, “If you think back 20 years, cigarettes were a lot more visible than they are right now and that is thanks to things like smoking and advertising bans, point of sale, display bans etc.”

These measures corresponded with sustained decreases in smoking rates in the UK. But the tobacco industry still has ways of finding new customers, and from a commercial point of view, the younger they start, the better.

The industry benefits from understanding who they’re selling to and what makes someone more likely to smoke. And by playing puppet master with targeted marketing strategies, they’ve cultivated reliable customer bases in society.

“There’s evidence of the tobacco industry really putting a lot of effort into targeting specific groups,” explains Hartmann-Boyce. “For example, the LGBTQ+ community has been really targeted by the tobacco industry.”

Historically, this targeting was very direct, and included promoting smoking in LGBTQ+ media, as well as sponsoring pride events and running adverting campaigns in LGBTQ+ publications.

One extreme example is a targeted campaign in the 90s dubbed ‘Project SCUM’ (allegedly an acronym for ‘sub culture urban marketing’), which aimed to increase sales in gay and homeless groups in San Francisco.

Nowadays, the tobacco industry still profits in a big way from the LGBTQ+ community. According to ONS data from 2018, smoking was far higher in people identifying as gay or lesbian (22.2%), than it was in people identifying as straight (15.5%).

Smoking and mental health

Of course, it’s not just industry that puts some groups at higher risk of tobacco harm. There are many other reasons for higher smoking rates in some marginalised groups, and the Venn diagram of at-risk groups overlaps considerably.

For example, both LGBTQ+ groups and more deprived groups are more likely to experience mental health difficulties than the general population. And people living with mental health conditions are, themselves, at a higher risk of smoking.

These overlaps are no mere coincidence. Inequalities in health, economic inequalities and social marginalisation are all inextricably linked.

We need collaborative action across government and society, including but not limited to health, to address health inequalities. But it’s also important to look at the direct drivers of smoking within specific groups.

One of the factors that could contribute to the pattern of smoking and mental health include the perception of smoking as a calming activity, or something to do in a stressful situation. Even some mental health professionals have expressed reluctance to help their patients to quit. After all, why would you want to add to the burden of someone living with a mental health condition?

But this is an illusion – temporary withdrawal from nicotine between cigarettes is another source of stress, and the sense of calm only comes from briefly addressing that nicotine withdrawal. In fact, research shows consistent mental health improvements following smoking cessation.

What can people who want to stop smoking do?

With wider determinants in mind, as well as industry targeting and access to support services varying greatly, it’s no wonder some groups find it harder to be healthy and are more likely to use tobacco and be affected by tobacco-related cancers.

Knowing about the wider determinants of health can sometimes feel disempowering. With such powerful forces at play, is there any hope for someone trying to reduce their own risk of cancer by stopping smoking?

“There are definitely things that an individual who smokes can do to increase their chances of successfully quitting.”

Hartmann-Boyce explains that there are several options available for someone looking to stop smoking, from medications to nicotine replacement therapy, behavioural support and nicotine containing e-cigarettes.

Most effective of all is a combination of prescription medicine and behavioural support from free, local stop smoking services. This approach is 3 times more likely to help someone stop smoking than willpower alone.

Hartmann-Boyce offered more encouragement for people trying to stop. “The important thing is to remember is that you can keep trying, so just because you haven’t succeeded once, doesn’t mean you won’t succeed next time. Most people who successfully quit smoking have tried multiple times.”

Who’s responsible for the UK’s health?

As individuals, there are things we can do to reduce our risk of cancer. But across the UK population, it’s the wider determinants that drive our health, even though things like smoking maintain an illusion of free, individual choice and responsibility.

That illusion favours industries that profit from ill health and addiction. But it also masks the government’s responsibility and power over our health.

There’s much more government can do and need to do to protect people who are at higher risk of tobacco-related harm.

Governments across the UK must ensure they have ambitious and comprehensive tobacco control strategies that help them stub out smoking for good. This should include exploring bold new policy measures to prevent people from starting to smoke – like dissuasive cigarettes or raising the age of sale to 21 for example – as well as improving the availability of the existing services that help people who already smoke to stop. But this will require more funding – and as the manufacturers of such a harmful product, the industry should be made to foot the bill.

That’s why we’re asking the UK Government to implement a ‘polluter pays’ type fund: making Big Tobacco pay for the damage their products cause, but without being given any say in how the money is spent.

Rachel Orritt is a health information manager at Cancer Research UK

*UK-wide survey of 2,446 adults, Cancer Research UK’s Cancer Awareness Measure (September 2021)

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