Tobacco Control Strategy - Creating a Tobacco-Free Generation

Chapter 3 Smoking and Health Inequalities

Health inequalities remain a significant challenge in Scotland, with the poorest in our society dying earlier and experiencing higher rates of disease. This is most starkly demonstrated in terms of healthy life expectancy. In 2009-10, male healthy life expectancy at birth ranged from 68.5 in the least deprived quintile to 50.0 in the most deprived quintile - a difference of 18.5 years. For females, the equivalent figures were 70.5 and 52.5 years respectively - a difference of 18.0 years^[10].

The causes of these health inequalities are complex, with no single factor responsible for differences in health outcomes experienced by people from different socio-economic groups. However, the correlation in the distribution of healthy life expectancy and smoking prevalence rates across socio-economic group is striking.

Given the strong link between smoking and premature mortality, it is clear that the patterns of smoking prevalence rates shown in table 1 are a very direct cause of Scotland's continuing health inequalities. It therefore follows that reducing smoking prevalence rates in the most deprived communities will make a decisive contribution to reducing Scotland's health inequalities.

However, it will not be possible to achieve this targeted reduction without understanding why smoking prevalence is so heavily concentrated in areas of deprivation. This means taking steps to address the underlying causes of health inequalities, which include factors such as negative early years' experiences, poverty, unemployment, low educational attainment and poor physical and social environments.

This Strategy therefore sets out a dual approach to tackling smoking-related health inequalities, by:

• ensuring all tobacco control measures are tailored to meet the requirements of Scotland's most deprived communities
• maintaining efforts to address the underlying causes of health inequalities.

Underlying Causes

The Scottish Government's approach to tackling health inequalities is set out in Equally Well, the Report of the Ministerial Task Force on Health Inequalities. Equally Well made clear that, in order to reduce Scotland's unfair and unjust health inequalities, we need to improve the whole range of circumstances and environments that offer opportunities to improve people's life chances and hence their health.

The Scottish Government's policies to ensure children have the best start in life through the Early Years Framework, Getting it Right for Every Child (GIRFEC), the Parenting Strategy and the Children and Young People (Scotland) Bill; to tackle poverty through Achieving Our Potential and the Child Poverty Strategy; to promote employability through Working for Growth; to improve educational attainment through Curriculum for Excellence; to reduce offending through the Strategy for Justice; and to improve the built environment through the Regeneration Strategy are all relevant to tackling health inequalities in Scotland. Whilst these strategies all offer opportunities to promote tobacco control messages, they also help to create the circumstances in which those messages are more likely to be heard and acted upon.

Action: The Ministerial Task Force on Health Inequalities will reconvene in 2012-13 to review and refresh the Scottish Government's strategy for addressing the root causes of health inequalities.

Lead: Scottish Government

Asset-based Approaches

It is clear that the ability and willingness of people to adopt the sorts of healthy behaviours that will lead to increased life expectancy - such as a tobacco-free lifestyle - depend significantly on their wider life circumstances. In order to respond to this challenge, the Chief Medical Officer for Scotland, supported by the Scottish Government and COSLA, advocates an asset-based approach to health improvement. Assets can be described as the collective resources which individuals and communities have at their disposal, which protect against negative health outcomes and promote health status. Asset-based approaches recognise that sustained positive health and social outcomes will only occur when people and communities have the opportunities and facility to control and manage their own futures.

In order to assist with embedding asset-based approaches in practice, the Glasgow Centre for Population Health has produced a series of briefing papers. These include setting out the evidence base for asset-based approaches, guidance on putting asset-based approaches into practice and a collection of case studies illustrating how asset-based approaches are currently being applied in Scotland.

This Strategy promotes an asset-based approach to the design and delivery of all smoking prevention, protection and cessation programmes. Critically, the adoption of asset-based approaches will enable deprived communities to engage on an equal basis with public and voluntary sector organisations to address key determining factors which impact on their health behaviour.

A Partnership Approach

Asset-based approaches, by definition, require a local approach. Given the wide range of factors that impact on smoking prevalence - and on health and wellbeing more widely - it is clear that effective local tobacco control strategies require a partnership response. Reducing the number of people who take up smoking is key to reducing overall prevalence rates and, as such, should be a key feature of local tobacco control strategies. Since the publication of Scotland's Future is Smoke Free (2008), NHS Boards have received annual prevention funding to deliver local initiatives that support young people to not smoke. Working with local partners will be key to getting the most out of this investment. Community Planning provides the context in which this work needs to take place with the opportunity to set local targets in support of reducing prevalence rates.

In 2012, the Scottish Government and COSLA carried out a review of Community Planning and Single Outcome Agreements (SOAs). New SOAs are expected to demonstrate a clearer focus on reducing inequalities within and between communities, in relation to six agreed national priorities, one of which is health inequalities.

The 2012 Guidance to Community Planning Partnerships on Single Outcome Agreements sets out how Community Planning Partnerships (CPPs) will mobilise public sector assets, activities and resources, together with those of the voluntary and private sectors and local communities, to deliver a shared and binding 'plan for place'. Local tobacco control plans should embrace these principles in setting out how they will interact with other health improvement work to support CPPs to reduce health inequalities.

Action: Local Authorities and NHS Boards should work with partners in the voluntary sector and local communities to develop local tobacco control plans. These plans should be integrated with wider health improvement activity to help Community Planning Partnerships reduce health inequalities as set out in 2013 Single Outcome Agreements.

Lead: Local Authorities/NHS Boards/CPPs

Health Inequalities Impact Assessment

All actions identified in this Strategy need to be implemented in a way that recognises the continued need to reduce inequalities. A clear understanding of how tobacco use is influenced by our personal characteristics and the impact of discrimination on health, the social determinants of health and realisation of our human rights is fundamental to the Strategy's contribution to the reduction of health inequalities. This involves recognising not only socio-economic inequalities, but also other types of inequality, including patterns of tobacco usage among black and minority ethnic groups. To that end, the implementation of this Strategy will be informed by a Health Inequalities Impact Assessment, facilitated by NHS Health Scotland.

Action: The recommendations of the Health Inequalities Impact Assessment will be incorporated in the implementation of this Strategy.

Lead: Scottish Government/NHS Health Scotland