This essay will be addressing health inequalities in the UK. I shall be discussing the rationale and significance of this topic, critically analysing the research evidence and relevant policy documents in the area, relate this equality to already laid out theories of health inequalities and a critical evaluation of interventions put in place to tackle this inequality.
Tobacco smoking is said to have started at about 1000BC amongst the Mayan civilisation of the Americas and hundreds of years later, it was discovered by the great explorers on their journeys to the Americas and was taken back to their respective countries. Tobacco smoking wasn’t easily accepted as the thought of letting smoke out of the nose and mouth was strange and considered akin to demonic possession. It slowly gained acceptance and popularity and by the turn of the 18th century, vast amounts of tobacco were being imported into the UK. In America, it became a protected crop and was recommended to soldiers during the two world wars to help boost soldier’s morale and to keep them busy. These soldiers upon coming home introduced tobacco to their families, further strengthening an already popular trend. By the beginning of the 20th century, tobacco smoking in the form of pipes, cigars and tobacco was widely accepted and in some cases considered as a thing of class. The affluent and learned, celebrities and role models were smokers.
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By the mid 20th century however, studies linking tobacco smoking to disease conditions began emerging. Of note, two prominent studies suggested that this ever popular trend was not healthy and in fact dangerous to health. Wynder and Graham reported that cigarette smoking was an important etiological factor for bronchiogenic carcinoma (Wynder and Graham, 1950), while Richard Doll and Bradford Hill conducted a prospective study involving over 30,000 British doctors and reported that both lung cancer and heart disease were more prevalent in smokers than non-smokers (Doll and Hill, 1954).
Since the awareness of the hazards (cancers, organ failures, etc) to health tobacco smoking presents, a lot of interventions and policies have been put in place to help curb this already accepted threat. Interventions and policies such as;
increasing tobacco taxation
banning of promotion of tobacco products
smoking restrictions in indoor workplace
availability of smoking cessation therapies
Telephone help lines.
With increasing health warnings, and government policies and interventions, smoking trends have significantly reduced. Great Britain in 2005 had about 24 per cent of adult 16yrs and over smoking. This is in contrast to 45 per cent in the 1970’s (survey, 2005).
“Smoking has been identified as the single greatest cause of preventable illness and premature death in the UK. â€¦it is estimated that half the difference in survival to 70 years of age between social class I and V is due to higher smoking prevalence in class V.”
Wanless D (2004) Securing Good Health for the Whole Population. London: TSO
According to McKeown (McKeown, 1976, p179), biomedical research will still play a large role in the management of diseases but more attention has to be into the modification of the conditions whch led to the disease rather than interventions after the disease has occurred. Ever since the Black Report was published in 1980, a lot of attention has been shifted to health inequalities in relation to socio-economic groups in particular and it has been appreciated as a major public health concern. The rationale for choosing smoking as a health inequality lies in the fact that despite a reduction in the overall prevalence of tobacco smoking in the UK over the past 30 years, there has been a slower reduction in smoking rates among lower income groups, and little or no change over the past decade (Department of Health. Smoking kills: a white paper on tobacco. London: The Stationery Office, 1998). It is an approachable problem and theories to explain the possible reasons for this will be discussed later in this essay.
SMOKING PREVALENCE BY SEX AND SOCIO ECONOMIC GROUP
Adam Crosier Published By : Public Health Research Consultant Published : 23/11/2005
Tobacco smoking is one of the top causes of preventable death globally and is estimated to kill more than 5 million people every year worldwide, most of which are in between low and middle income countries. It is projected that by the year 2030, this figure will rise to about 8 million people. The burden of tobacco cannot go without mentioning its financial implications and costs to the economy. According to the WHO, tobacco’s cost to governments, employers and to the environment includes social, welfare and health care spending, loss of foreign exchange in importing cigarettes, loss of land that could grow food, cost of fire and damage to buildings caused by careless smoking, environmental costs ranging from deforestation to collection of smokers’ litter, absenteeism, decreased productivity, higher number of accidents and higher insurance premiums.
USA $76 billion
UK $2.26 billion
Canada $1.6 billion
Germany $14.7 billion
China $3.6 billion
Philippines $600 million
Australia $6 billion
New Zealand $84 million
(Mackay and Eriksen, 2002)
With the economic burden of tobacco smoking mentioned, the implications on individuals with low socio-economic background are vast. Some of these issues include:
Cost of smoking/income ratio: the cost of 20 cigarettes/day at £5 per pack is about £1800 pounds annually. Clearly this will give a disproportionate effect on living conditions in individuals with a low socio-economic background in relation to individuals who earn more and in fact, professor Alan Marsh in his book ‘poor smokers’ suggests that households in the lowest tenth of income spend 6 times as much of their income on tobacco as households in the highest tenth (Marsh A, McKay S. Poor smokers. London: Policy Studies Institute, 1994)
Tobacco smoking is the biggest contributor to the widening gap in health inequality between advantaged and disadvantaged people. (Department of Health. Smoking kills: a white paper on tobacco. London: The Stationery Office, 1998.)
Economically disadvantaged people commence smoking at a relatively younger age than advantaged people.
They are more likely to be nicotine dependent and will find it harder to quit smoking.
Children living in low income households are more likely to be exposed to tobacco smoke, largely influencing the likelihood of the child becoming a smoker.
Analysis of the available data and findings from previous researches or even policies available dat address the inequality e.g contributing factors, degree of inequality and how it affects lives.
Critical analysis of issues surrounding inequality
THE CONCEPT OF HEALTH INEQUALITY IN SMOKING
As far back as the 19th century in England, the use of occupation to analyse the health of the population took place and striking differences in death rates were observed between certain occupations (annual reports of the registrar general in England, 1875 and 1885). Various other studies were done using socio-economic status such as works done by Rowntree (Rowntree, 1901), and Stevenson in 1911. But as earlier mentioned, the Black report was one of the most recognised works on the area of health inequality. The report identified the importance of deprivation in the home, at work, in education, environment, the upbringing of future generations as it affects health and how this may be causative factor for health inequality amongst social classes (Black, Morris and Townsend, 1982, p134).
Clearly this wasn’t solely a result of inaccess to health services because the Britain for example had started free health services for its citizens since the 1950’s yet inequality in health not only existed but over the times, the gap seems to have widened even more. The Black report tried to give reasons for this putting forward three explanations which are the materialist, cultural-behavioural and selection.
The materialist interpretation theory suggests that low wages and its consequences could be the cause of health inequality. Issues relating to this are issues concerning education, housing,
The cultural-behavioural suggests that emphasis should be on the possibility that different cultures might be prevalent in lower income groups or less privileged class. Certain behavioural patterns have been associated with certain health behaviours for example people in manual labour or lower economic backgrounds have been known to share smoking behaviour.
The final suggestion by the Black report is selection. The concept is derivative from Darwin’s law of selection and survival of the fittest and that people who had a tendency to be sickly will most likely end up in positions of lower socio-economic status. As such people in lower paid, manual jobs tend to be sick because they have always had the tendency to be sick while healthier and perhaps more intelligent persons get zoned into social classes with higher levels of occupational skills.
CAUSE OF SOCIO-ECONOMIC GRADIENT IN SMOKING
The socio-economic gap in smoking has been highlighted for its role in increased death rates amongst people in lower socio-economic backgrounds (JARVIS m.j & Wardle J. (1999) social patterning of health behaviours: the case of cigarette smoking. In social determinants of health (Eds M. Marmot M. & R.G wilkinson R.G), oxford university press, oxford.). Simply put, individuals from a disadvantaged socio-economic background will have a higher tendency to start smoking and also to quit smoking than individuals from a higher socio-economic background (roger Dobson, 2004: poor more likely to smoke and less to quit; BMJ. 2004 april 17; 328(7445): 914)
This can be said to be the primary causative factors for the gradient but even these causative factors are in themselves affected by other larger themes which will be discussed next.
The reason for this gradient can be said to be primarily a result of physical impression (materialist, environment) and psychological impression (behaviour-cultural).
THEORIES OF HEALTH INEQUALITIES
Mel Bartley in his book health inequality, identified 4 main models for health inequality namely
For the purpose of this essay, i will be discussing the behaviour-cultural theory and the life course theory because in my opinion, this is the most relevant to health inequality in smoking.
BEHAVIOURAL-CULTURAL: this is said to be one of the most widely accepted causes of health inequality. It was originally mentioned in the Black report where it was described as the reckless, irrational, irresponsible or incautious lifestyle as the moving determinant of poor health status. The model suggests that influence from cultural or behavioural patterns can be a very large determinant of total health and wellbeing of a person. And as such, there is a relatively higher chance of smoking inception amongst children from poorer backgrounds in comparison to children from more affluent backgrounds. Though according to Jarvis et al in the paper on social patterning of health (Jarvis m.j and Wardle J (2005) social patterning of health behaviours: the case of cigarette smoking. In: Marmot, M. And Wilkinson, R. (eds) social determinants of health. Oxford: oxford university press, 2nd edition), the difference isn’t well obvious until these children reach their thirties and half of the individuals from affluent backgrounds quit while two thirds of the individuals from poorer backgrounds continue smoking.
Various explanations under this model that can be used to explain the smoking gradient between the affluent and the poorer socio-economic groups include
People from a lower socio-economic background have less self control
Inability to grasp the extent of danger tobacco smoking offers.
Relatively higher inception of smoking rates
Relatively lower quit rate in the disadvantaged groups.
Individuals from disadvantaged backgrounds are relatively more burdened by financial and economic worries than people in affluence and see smoking as a release and stress reliever.
People in advantaged groups are more likely to want to stay there and will not want to engage in unhealthy behaviours such as smoking. Their children too will most likely acquire certain disposition to unhealthy behaviours as well.
Smoking can be seen as a way to manage stress, and deal with the hassles of living with deprivation
And finally, the more the habit builds acceptance within communities and individuals with deprivation, the stronger the trend will be and the harder it will be to curb it eventually developing into a vicious cycle that might engulf future generations from this communities.
Sadly, tobacco smoking isn’t a habit that can be picked then dropped with ease particularly because nicotine, an active ingredient of tobacco is addictive making incidence far more important than prevalence in this case.
Ultimately, the behaviour cultural theory provides the most acceptable explanations for health inequalities in smoking. I will briefly attempt to use the life course theory to explain this as well.
This comes out as one of the newest theories in health inequalities. This concept this idea puts forward is that health and health behaviour is a result of a complex combination of events that have happened throughout the life course of the individual (davey smith, ben-shlomo and lynch, 2002, life course approaches to inequalities in coronary heart disease risk. In S.stanfield and m.marmot (eds) stress and the heart, 20-49. London: BMJ books). Basically it means then that whatever we are now or whatever decisions we make is a function of a combination of occurrences and experiences of the past. Certain factors can accumulatively lead to the smoking gradient observed. Factors such as environment, housing, employment, lack of education, type of job, marriage, children, bills and so on. These are factors that are more appreciated in the lives of people living in deprivation as opposed to people in affluence and could be a possible explanation for the inequality gap in smoking between the affluent and deprived.
STRATEGIES AND MEASURES.
Since the awareness of the hazards of tobacco, and the socio-economic inequality seen in this area, the government has tried to implement regulations, policies and legislation to help if not stop, at least measurably reduce the prevalence of this ill. It has been quite a problematic issue to tackle as it has to do with peoples choices. In 1998, the government released a paper (the White paper) to address the issues concerning the tobacco epidemic and one of its objectives was to establish a downward trend in adult smoking rates in all social classes. The paper proposed to have 1.5million fewer smokers by 2010 by implementing certain key legislation, policies across Europe. Some of the interventions are
Action on tobacco smuggling
Mass media campaigns
Enforcement of underage sales
NHS smoking cessation services
One week free nicotine replacement therapy (NRT)
These laws and legislation have been effective and the reduction in incidence and prevalence across social status can be attributed to it. Tax on tobacco in the UK for example accounts for over 75% of the cost of a 20 cigarette pack (howard reed 2010. The effects of increasing tobacco taxation: a cost benefit and public finances analysis). Increased tobacco taxes prevent smoking initiation and also help smokers to reduce the quantity of cigarette smoked. Apart from it being a great source of revenue for the government, a reduction in prevalence and incidence rates means better health and less expenditure on preventable diseases attributable to tobacco smoking. Perhaps the only argument against taxation is that with every addiction; an increase in price usually isn’t enough to result in a complete cessation of the addiction. In this case though, it has made a remarkable impact.
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The role of the media in any society cannot be over emphasized. The tobacco smoking trend was strengthened by adverts in the media and in return, mass media campaigns which include radio, television, newspaper, have and will continue to go a long way in fighting the tobacco epidemic. Education of people in socially deprived areas about the destruction in tobacco will go a long way to reduce the rates of consumption amongst these groups.
The National free NRT (nicotine replacement therapy) was a welcome development. The only problem however was that it was free for just a week…, too short to make a good enough impact or to observe a noticeable enough change to want to continue its use.
The enforcement of underage sales and clamping down on the illegal smuggling of tobacco into the UK are also important issues. Smuggling of tobacco products into the UK negates the benefits of taxation because then, tobacco will be sold at a less price than the ones with taxes on them, increasing the availability of tobacco. Smuggling in tobacco also means that its sales cannot be regulated as it should. Enforcement of these issues have been tight, there however still exists some lapses.
There has been a reduction in prevalence and incidence rates in tobacco smoking. There exists however, a gradient between people from affluent backgrounds and individuals from disadvantaged backgrounds and it has been shown that people from less disadvantaged backgrounds have higher incidence and prevalence rates. I have used the behaviour-cultural theory of health inequality to give possible explanations for this. For a fact, a country where wealth is evenly distributed, these kinds of issues of health inequality and in smoking in particular will not be expected. But until the UK gets to a level of even wealth distribution, continued vigilance and efforts will be required to help maximally reduce the problem.
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