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EDITORIAL
doi:10.1111/add.12548
The importance of tobacco research focusing on marginalized groups
Research on tobacco use in marginalized groups with high smoking prevalence should receive greater priority for publication in high-impact journals, not just because of the tobacco-related harm these populations experience, but also because of the greater understanding such research can provide on what drives tobacco use and undermines quitting in the human population generally.
INTRODUCTION Tobacco use in many high-income countries is increasingly dominated by marginalized groups that experience the greatest social and economic disadvantage. These include Indigenous people, homeless people, those with substance abuse or mental illness and those of low socioeconomic status [1]. Smoking adds to the disadvantage experienced by these groups, further exacerbating health, social and financial inequities [2]. The increasing disparities in smoking rates suggest that current tobacco control approaches, and the science on which they are based, do not adequately meet the needs of these populations. Despite the heightened smoking-related burden, research with marginalized groups continues to represent a small proportion of published tobacco research [3]. Intervention studies providing an evidence base for effective tobacco dependence treatments for these smokers are scarce [3,4]. There is also a sense that high-impact journals have a tendency to consider manuscripts addressing some marginalized groups (e.g. Indigenous populations) as occupying a specialist niche of low priority. Here we outline some of the main benefits of tobacco research with marginalized groups and argue for greater priority for research in this area and for it to be considered as a priority for publication in high-impact journals.
BENEFIT 1. BETTER UNDERSTANDING OF FACTORS DRIVING DIFFERENCES IN SMOKING AND QUITTING RATES The excessive smoking prevalence among disadvantaged groups is striking. General adult population smoking rates in the United Kingdom, United States, Canada, New Zealand and Australia range from 16 to 21% [4]. However, across countries, smoking prevalence ranges from 68 to 89% among homeless populations, from 30 to © 2014 Society for the Study of Addiction
62% among people with mental illness and from 56 to 93% among people with substance use disorders [4]. The reasons for these disparities are complex and poorly understood. Smokers from disadvantaged groups report higher rates of uptake with earlier initiation, heavier nicotine dependence and lower rates of cessation [2]. UK research shows that lower socio-economic smokers make as many quit attempts and are as motivated to quit as the more advantaged, but are less successful at achieving cessation [5]. Others report that financially stressed smokers have greater interest in quitting, but make fewer quit attempts [6]. Understanding the factors which undermine motivation to try to quit, or success when cessation is attempted, and how these vary by socio-economic status, will yield valuable information for targeting cessation treatments. Similarly, little is known about the drivers of smoking among marginalized groups, which may vary depending on the socio-cultural context and values of the group [7]. For example, the socio-cultural drivers of smoking for people from a marginalized ethnic group may well be different from those for people with severe mental illness or homeless people. This suggests that a ‘one size fits all’ approach may be inappropriate, and that multiple frameworks are needed. Research among one marginalized group may also inform development of further research in other settings, building the evidence regarding the diversity of drivers of smoking in different socio-cultural groups. This enables greater understanding of the commonalities and differences across the human population, contributing to a more comprehensive science of addictive behaviour.
BENEFIT 2. AN EVIDENCE BASE FOR DELIVERY OF TOBACCO DEPENDENCE TREATMENTS ACCORDING TO SOCIAL OR CULTURAL CONTEXTS Applying interventions known to reduce overall smoking behaviour will not necessarily reduce inequalities, as some interventions impact negatively upon the most disadvantaged [8]. Ceci & Papiemo argue that in order to address health disparities, interventions that are tailored for each marginalized group are needed [9]. However, most primary research and systematic reviews do not assess the differential effectiveness of tobacco cessation interventions across socio-cultural groups [10]. A recent Addiction, 109, 1049–1051
1050
Editorial
systematic review of peer-support programmes for smoking cessation in disadvantaged groups suggests that these may have greater value for disadvantaged than advantaged groups, particularly those with less access to informal support [11]. A meta-analysis of smoking cessation behavioural interventions in six marginalized groups found 32 controlled trials (n = 1 homeless, n = 2 Indigenous populations, n = 1 prisoners, n = 6 at-risk youth, n = 12 low-income groups, n = 10 mental illness). The included studies showed promising effectiveness of behavioural interventions for some groups; however, few studies were available within each group. Poor access and reach also probably contribute to reduced impact of smoking cessation services. Greater research effort into ways to increase the reach of existing cessation treatments and improve access for marginalized groups will yield useful information. For example, traditional health-care settings may not be the best access point, and more innovative settings, such as social welfare agencies [12], drug and alcohol services [13] or homeless shelters [14] may prove more fruitful.
BENEFIT 3. AN EVIDENCE BASE TO ENSURE THAT POPULATION-WIDE TOBACCO CONTROL POLICIES ARE REDUCING DISPARITIES The primary purpose of tobacco control research is to underpin the development of policies and programmes that reduce population smoking rates and address inequalities. A number of recent literature reviews have challenged the effectiveness of tobacco control policies at achieving equity [8,15]. The only strategy identified by these reviews as reducing inequities was taxation. Many other commonly implemented tobacco control strategies such as smoke-free environments, media campaigns, health warnings and community-wide cessation support either showed mixed effects, had limited evidence or exacerbated inequities. Similarly, a review of European smoking cessation support found that non-targeted cessation services generally have a negative equity impact, but that services targeted specifically to disadvantaged groups in the United Kingdom were reducing inequities [16]. Graham has also identified the importance of examining the unintended, inequitable consequences of smoking cessation policies, such as increasing the stigmatization of smokers themselves [17]. These reviews highlight the need for research which evaluates the equity impact of population-level tobacco control measures, including unintended consequences, as well as research that improves understanding of the varied drivers of smoking among marginalized groups to inform targeting of strategies more effectively. © 2014 Society for the Study of Addiction
HIGHER-PROFILE PUBLICATION IS NEEDED DESPITE METHODOLOGICAL CHALLENGES While there are clear benefits to conducting tobacco research with marginalized groups, there are also many challenges. Most groups with the highest smoking rates are ‘hard-to-reach’ and consequently present methodological challenges in sampling, recruitment, retention, literacy and compliance [18]. These and other challenges make research with most marginalized groups both difficult and resource-intensive. Methodological research to validate innovations is needed to support rigorous research in this area. The full range of research designs will be necessary in developing understanding of how and why theoretically developed interventions have less impact than expected, and identifying more appropriate approaches [19]. Research focusing on interventions with marginalized groups will help to elucidate the processes and mechanisms of change, facilitating theoretical development, while studies using a comparative design should assess the differential impact of interventions by group.
Declaration of interests B.B. was supported by Cancer Institute NSW Career Development Fellowship (10/CDF/2-40). Keywords Evidence, indigenous, groups, priority, research, tobacco.
marginalized
MEGAN PASSEY1 & BILLIE BONEVSKI2
University Centre for Rural Health—North Coast, University of Sydney, Lismore, NSW, Australia1 and School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.2 E-mail: [email protected]
References 1. McLachlan R., Gilfillan G., Gordon J. Deep and Persistent Disadvantage in Australia. Canberra: Productivity Commission; 2013. 2. Marmot M. Smoking and inequalities. Lancet 2006; 368: 341–2. 3. Paul C. L., Sanson-Fisher R., Stewart J., Anderson A. E. Being sorry is not enough: the sorry state of the evidence base for improving the health of Indigenous populations. Am J Prev Med 2010; 38: 566–8. 4. Bryant J. Tackling tobacco: an exploration of social and community service organisations as a way of reaching the socially disadvantaged for smoking cessation [PhD Dissertation]. Newcastle: University of Newcastle; 2011. 5. Kotz D., West R. Explaining the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tob Control 2009; 18: 43–6. Addiction, 109, 1049–1051
Editorial
6. Siahpush M., Yong H. H., Borland R., Reid J. L., Hammond D. Smokers with financial stress are more likely to want to quit but less likely to try or succeed: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction 2009; 104: 1382–90. 7. Paul C., Ross S., Bryant J., Hill W., Bonevski B., Keevy N. The social context of smoking: a qualitative study comparing smokers of high versus low socioeconomic position. BMC Public Health 2010; 10: 211. 8. Lorec T., Petticrew M., Welch V., Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health 2013; 67: 190–3. 9. Ceci S. J., Papiemo P. B. The rhetoric and reality of gap closing: when the have-nots gain but the haves gain even more. Am Psychol 2005; 60: 149–60. 10. Ogilvie D., Petticrew M. Reducing social inequalities in smoking: can evidence inform policy? A pilot study. Tob Control 2004; 13: 129–31. 11. Ford P., Clifford A., Gussy K., Gartner C. A systematic review of peer-support programs for smoking cessation in disadvantaged groups. Int J Environ Res Public Health 2013; 10: 5507–22. 12. Bonevski B., O’Brien J., Frost S., Yiow L., Oakes W., Barker D. Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes. Health Educ Res 2012; 28: 46–57.
© 2014 Society for the Study of Addiction
1051
13. Bowman J., Wiggers J. H., Colyvas K., Wye P. M., Walsh R. A., Bartlem K. Smoking cessation among Australian methadone clients: prevalence, characteristics and a need for action. Drug Alcohol Rev 2011; 31: 507–13. 14. Bonevski B., Baker A., Twyman L., Paul C., Bryant J. Addressing smoking and other health risk factors using a novel telephone-delivered intervention for homeless people: a proof-of-concept study. Drug Alcohol Rev 2012; 31: 709– 13. 15. Hill S., Amos A., Clifford D., Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tob Control 2013; doi: 10.1136/tobaccocontrol-2013-051110 [Epub ahead of print]. 16. Amos A., Brown T., Platt S. A systematic review of the effectiveness of individual cessation support interventions in Europe to reduce socio-economic inequalitites in smoking among adults. Amsterdam/Edinburgh: UK Centre for Tobacco and Alcohol Studies and the University of Edinburgh for SILNE; 2013. 17. Graham H. Smoking, stigma and social class. J Soc Policy 2012; 41: 83–99. 18. Brackertz N. Who is hard to reach and why. ISR Working Paper. Melbourne: Institute for Social Research; 2007. 19. Sanson-Fisher R., Bonevski B., Green L. W., D’Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions. Am J Prev Med 2007; 33: 155–61.
Addiction, 109, 1049–1051
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
EDITORIAL
doi:10.1111/add.12548
The importance of tobacco research focusing on marginalized groups
Research on tobacco use in marginalized groups with high smoking prevalence should receive greater priority for publication in high-impact journals, not just because of the tobacco-related harm these populations experience, but also because of the greater understanding such research can provide on what drives tobacco use and undermines quitting in the human population generally.
INTRODUCTION Tobacco use in many high-income countries is increasingly dominated by marginalized groups that experience the greatest social and economic disadvantage. These include Indigenous people, homeless people, those with substance abuse or mental illness and those of low socioeconomic status [1]. Smoking adds to the disadvantage experienced by these groups, further exacerbating health, social and financial inequities [2]. The increasing disparities in smoking rates suggest that current tobacco control approaches, and the science on which they are based, do not adequately meet the needs of these populations. Despite the heightened smoking-related burden, research with marginalized groups continues to represent a small proportion of published tobacco research [3]. Intervention studies providing an evidence base for effective tobacco dependence treatments for these smokers are scarce [3,4]. There is also a sense that high-impact journals have a tendency to consider manuscripts addressing some marginalized groups (e.g. Indigenous populations) as occupying a specialist niche of low priority. Here we outline some of the main benefits of tobacco research with marginalized groups and argue for greater priority for research in this area and for it to be considered as a priority for publication in high-impact journals.
BENEFIT 1. BETTER UNDERSTANDING OF FACTORS DRIVING DIFFERENCES IN SMOKING AND QUITTING RATES The excessive smoking prevalence among disadvantaged groups is striking. General adult population smoking rates in the United Kingdom, United States, Canada, New Zealand and Australia range from 16 to 21% [4]. However, across countries, smoking prevalence ranges from 68 to 89% among homeless populations, from 30 to © 2014 Society for the Study of Addiction
62% among people with mental illness and from 56 to 93% among people with substance use disorders [4]. The reasons for these disparities are complex and poorly understood. Smokers from disadvantaged groups report higher rates of uptake with earlier initiation, heavier nicotine dependence and lower rates of cessation [2]. UK research shows that lower socio-economic smokers make as many quit attempts and are as motivated to quit as the more advantaged, but are less successful at achieving cessation [5]. Others report that financially stressed smokers have greater interest in quitting, but make fewer quit attempts [6]. Understanding the factors which undermine motivation to try to quit, or success when cessation is attempted, and how these vary by socio-economic status, will yield valuable information for targeting cessation treatments. Similarly, little is known about the drivers of smoking among marginalized groups, which may vary depending on the socio-cultural context and values of the group [7]. For example, the socio-cultural drivers of smoking for people from a marginalized ethnic group may well be different from those for people with severe mental illness or homeless people. This suggests that a ‘one size fits all’ approach may be inappropriate, and that multiple frameworks are needed. Research among one marginalized group may also inform development of further research in other settings, building the evidence regarding the diversity of drivers of smoking in different socio-cultural groups. This enables greater understanding of the commonalities and differences across the human population, contributing to a more comprehensive science of addictive behaviour.
BENEFIT 2. AN EVIDENCE BASE FOR DELIVERY OF TOBACCO DEPENDENCE TREATMENTS ACCORDING TO SOCIAL OR CULTURAL CONTEXTS Applying interventions known to reduce overall smoking behaviour will not necessarily reduce inequalities, as some interventions impact negatively upon the most disadvantaged [8]. Ceci & Papiemo argue that in order to address health disparities, interventions that are tailored for each marginalized group are needed [9]. However, most primary research and systematic reviews do not assess the differential effectiveness of tobacco cessation interventions across socio-cultural groups [10]. A recent Addiction, 109, 1049–1051
1050
Editorial
systematic review of peer-support programmes for smoking cessation in disadvantaged groups suggests that these may have greater value for disadvantaged than advantaged groups, particularly those with less access to informal support [11]. A meta-analysis of smoking cessation behavioural interventions in six marginalized groups found 32 controlled trials (n = 1 homeless, n = 2 Indigenous populations, n = 1 prisoners, n = 6 at-risk youth, n = 12 low-income groups, n = 10 mental illness). The included studies showed promising effectiveness of behavioural interventions for some groups; however, few studies were available within each group. Poor access and reach also probably contribute to reduced impact of smoking cessation services. Greater research effort into ways to increase the reach of existing cessation treatments and improve access for marginalized groups will yield useful information. For example, traditional health-care settings may not be the best access point, and more innovative settings, such as social welfare agencies [12], drug and alcohol services [13] or homeless shelters [14] may prove more fruitful.
BENEFIT 3. AN EVIDENCE BASE TO ENSURE THAT POPULATION-WIDE TOBACCO CONTROL POLICIES ARE REDUCING DISPARITIES The primary purpose of tobacco control research is to underpin the development of policies and programmes that reduce population smoking rates and address inequalities. A number of recent literature reviews have challenged the effectiveness of tobacco control policies at achieving equity [8,15]. The only strategy identified by these reviews as reducing inequities was taxation. Many other commonly implemented tobacco control strategies such as smoke-free environments, media campaigns, health warnings and community-wide cessation support either showed mixed effects, had limited evidence or exacerbated inequities. Similarly, a review of European smoking cessation support found that non-targeted cessation services generally have a negative equity impact, but that services targeted specifically to disadvantaged groups in the United Kingdom were reducing inequities [16]. Graham has also identified the importance of examining the unintended, inequitable consequences of smoking cessation policies, such as increasing the stigmatization of smokers themselves [17]. These reviews highlight the need for research which evaluates the equity impact of population-level tobacco control measures, including unintended consequences, as well as research that improves understanding of the varied drivers of smoking among marginalized groups to inform targeting of strategies more effectively. © 2014 Society for the Study of Addiction
HIGHER-PROFILE PUBLICATION IS NEEDED DESPITE METHODOLOGICAL CHALLENGES While there are clear benefits to conducting tobacco research with marginalized groups, there are also many challenges. Most groups with the highest smoking rates are ‘hard-to-reach’ and consequently present methodological challenges in sampling, recruitment, retention, literacy and compliance [18]. These and other challenges make research with most marginalized groups both difficult and resource-intensive. Methodological research to validate innovations is needed to support rigorous research in this area. The full range of research designs will be necessary in developing understanding of how and why theoretically developed interventions have less impact than expected, and identifying more appropriate approaches [19]. Research focusing on interventions with marginalized groups will help to elucidate the processes and mechanisms of change, facilitating theoretical development, while studies using a comparative design should assess the differential impact of interventions by group.
Declaration of interests B.B. was supported by Cancer Institute NSW Career Development Fellowship (10/CDF/2-40). Keywords Evidence, indigenous, groups, priority, research, tobacco.
marginalized
MEGAN PASSEY1 & BILLIE BONEVSKI2
University Centre for Rural Health—North Coast, University of Sydney, Lismore, NSW, Australia1 and School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.2 E-mail: [email protected]
References 1. McLachlan R., Gilfillan G., Gordon J. Deep and Persistent Disadvantage in Australia. Canberra: Productivity Commission; 2013. 2. Marmot M. Smoking and inequalities. Lancet 2006; 368: 341–2. 3. Paul C. L., Sanson-Fisher R., Stewart J., Anderson A. E. Being sorry is not enough: the sorry state of the evidence base for improving the health of Indigenous populations. Am J Prev Med 2010; 38: 566–8. 4. Bryant J. Tackling tobacco: an exploration of social and community service organisations as a way of reaching the socially disadvantaged for smoking cessation [PhD Dissertation]. Newcastle: University of Newcastle; 2011. 5. Kotz D., West R. Explaining the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tob Control 2009; 18: 43–6. Addiction, 109, 1049–1051
Editorial
6. Siahpush M., Yong H. H., Borland R., Reid J. L., Hammond D. Smokers with financial stress are more likely to want to quit but less likely to try or succeed: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction 2009; 104: 1382–90. 7. Paul C., Ross S., Bryant J., Hill W., Bonevski B., Keevy N. The social context of smoking: a qualitative study comparing smokers of high versus low socioeconomic position. BMC Public Health 2010; 10: 211. 8. Lorec T., Petticrew M., Welch V., Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health 2013; 67: 190–3. 9. Ceci S. J., Papiemo P. B. The rhetoric and reality of gap closing: when the have-nots gain but the haves gain even more. Am Psychol 2005; 60: 149–60. 10. Ogilvie D., Petticrew M. Reducing social inequalities in smoking: can evidence inform policy? A pilot study. Tob Control 2004; 13: 129–31. 11. Ford P., Clifford A., Gussy K., Gartner C. A systematic review of peer-support programs for smoking cessation in disadvantaged groups. Int J Environ Res Public Health 2013; 10: 5507–22. 12. Bonevski B., O’Brien J., Frost S., Yiow L., Oakes W., Barker D. Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes. Health Educ Res 2012; 28: 46–57.
© 2014 Society for the Study of Addiction
1051
13. Bowman J., Wiggers J. H., Colyvas K., Wye P. M., Walsh R. A., Bartlem K. Smoking cessation among Australian methadone clients: prevalence, characteristics and a need for action. Drug Alcohol Rev 2011; 31: 507–13. 14. Bonevski B., Baker A., Twyman L., Paul C., Bryant J. Addressing smoking and other health risk factors using a novel telephone-delivered intervention for homeless people: a proof-of-concept study. Drug Alcohol Rev 2012; 31: 709– 13. 15. Hill S., Amos A., Clifford D., Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tob Control 2013; doi: 10.1136/tobaccocontrol-2013-051110 [Epub ahead of print]. 16. Amos A., Brown T., Platt S. A systematic review of the effectiveness of individual cessation support interventions in Europe to reduce socio-economic inequalitites in smoking among adults. Amsterdam/Edinburgh: UK Centre for Tobacco and Alcohol Studies and the University of Edinburgh for SILNE; 2013. 17. Graham H. Smoking, stigma and social class. J Soc Policy 2012; 41: 83–99. 18. Brackertz N. Who is hard to reach and why. ISR Working Paper. Melbourne: Institute for Social Research; 2007. 19. Sanson-Fisher R., Bonevski B., Green L. W., D’Este C. Limitations of the randomized controlled trial in evaluating population-based health interventions. Am J Prev Med 2007; 33: 155–61.
Addiction, 109, 1049–1051
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
