Chronic Disease and the Socially Disadvantaged Ian Olver AM

CEO Cancer Council Australia

Social Determinants of Health

Social and economic conditions and their

distribution that determine health

Risk factors e.g. availability of healthy food,

workplace environment, income, physical

environment, stress, addiction, early childhood

development etc.

Definition of chronic disease - DOH

Characteristics of chronic disease:

• Prolonged development and

duration

• No spontaneous resolution

• Rarely completely cure

• Contributes to death and or

disability

• Worse with aging

Chronic diseases in Australia (AIHW)

Ischaemic heart disease

Stroke

Lung cancer

Colorectal cancer

Depression

Type 2 diabetes

Arthritis

Osteoporosis

Asthma

Chronic obstructive pulmonary disease (COPD)

Chronic kidney disease

Oral disease

AIHW http://www.aihw.gov.au/burden-from-chronic-disease/

Prevalence: Department of Health

2007-08 National Health Survey indicates:

• cancer (2% of the population – up from 1.6% in 2001)

• diabetes (4% - up from 2.9% in 2001)

• asthma (10% - down from 12% in 2001)

• long-term mental or behavioural conditions (11% - up from fewer than

10% in 2001)

• arthritis (15% - up from 14% in 2001)

• conditions of the circulatory system (16% - down from 17% in 2001)

• The ageing population is key role in increased chronic disease

• 2007-08 National Health Survey nearly all 65 years and over had at least

one long-term condition (> 80 per cent of people > 3) cf 27% of children

• In 2010, chronic diseases were the leading causes of death in Australia,

including cardiovascular disease, cancer, chronic lung and diabetes

Chronic Disease

Impact of chronic disease

(Dept Health) • In 2006-07, arthritis, diabetes and depression accounted for 2.5% GP

consultations Australia's health 2008

• Over 1/2 of all potentially preventable hospitalisations are from chronic

conditions Australian hospital statistics 2007-08

• Ischaemic heart disease, stroke lung cancers, COPD and colorectal

cancer all featured in the top 10 leading causes of death in 2005.

Australia's health 2008

• Indigenous Australians experience higher levels of chronic conditions

than non-Indigenous Australians. In 2004-05 Indigenous health

• In 2004-05, people with chronic disease were less likely participate in

the labour force, be employed full-time, and more likely to be

unemployed Chronic disease and participation in work.

Australian Institute of Health and Welfare

Weight, smoking and alcohol by

location and social disadvantage

• Adults outside cities are more likely to be obese,

smoke, and face long term risk from alcohol

In main cities:

• Overweight and obesity increased between 2007-

8 and 2011-12 from 58.5 – 61.5%

• Smoking decreased from 17.6% to 14.8%

• Long term alcohol risk decreased

Adults in disadvantaged areas*

• Smoking which has dropped in the most

disadvantaged areas (from 28.7% to 24.5%) but is

still higher than in advantaged areas

• They are more likely to be overweight

• They are less likely to be at risk of long term

harm from alcohol

*Disadvantaged is bottom 20% and well off the top 20%

Australian Bureau of Statistics

Underlying Causes of Chronic

Disease - Smoking • Smoking rates are associated with socioeconomic status: the

proportion of smokers in the lowest socioeconomic status tier (24.6%) is

almost double that of the highest (12.5%)

• Disadvantaged populations have higher than average smoking rates

– single parents (37%)

– lone mothers 18–29 years of age (59%)

– people living with psychosis (66%)

– adults with mental illness (36%)

– at-risk young people (63%)

– people with drug disorders (73%)

– the homeless (73%)

– intravenous drug users (90%)

– prisoners (85%)

– ATSI (47%)

– those living in remote areas (28.9%)

– children of those who smoke at home

Link between smoking and disadvantage

• Disadvantage is associated with smoking; increased

disadvantage is associated with increased smoking prevalence

• For example, women in the UK were at increased odds of being a

heavy smoker if they experienced childhood disadvantage, left

school aged 16 or less, were a mother at age 22 or younger, or if

they experienced severe disadvantage as an adult

• The relationship between smoking and disadvantage has been

shown to be cumulative, that is as the number of experiences of

disadvantage accrue smoking rates increase

Graham H, Inskip HM, Francis B, Harman J. Pathways of disadvantage and smoking careers:

evidence and policy implications J Epidemiol Community Health 2006 Sep;60 Suppl 2:7-12

[Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17708005].

Smoking and disadvantage

• Smoking accounts for more than half the

difference in mortality between men in the top

and bottom social strata

• Disparities in health status between

Indigenous Australians and the total

population account for 59% of the total

burden of disease for Indigenous Australians

• Smoking accounts for 17% of this health gap,

making it the primary risk factor contributing

to health disparities in Indigenous Australians

Smoking and disadvantage

• As well as health impacts, tobacco contributes to poverty and

disadvantage through:

– the cost of tobacco-related illness

– loss of family breadwinner

– impact on family stress and finances

– impact on children’s education and employment opportunities

• Spending on tobacco products, school absence and loss of

income due to smoking-related illness reduces the capacity of a

household:

– to accumulate assets such as a family home

– to insure against losses

– to save for financial requirements in retirement and to pass on assets to the next

generation

• In addition, higher smoking prevalence among adults in lower

socio-economic families is associated with higher uptake of

smoking among children from these families, continuing the

cycle of financial stress and ill health

Smoking and Poverty • Tobacco exacerbates the impact of poverty by

reducing funds available for food, clothing + housing

• Households that smoke are 3 times more likely to

experience severe financial stress and go without

meals or home heating than non-smoking households

• Children in smoking households are 2x as likely to

experience food insecurity and 3x severe food

insecurity than children in non-smoking households

• In the lowest-income households, expenditure on

tobacco products as a proportion of total household

weekly expenditure is over 2x that in the highest

income households

Barriers to Quitting in Disadvantaged

• Heavier nicotine dependence

• Experiencing financial stress

• Friends, family and communities with a high prevalence of smoking

• facing daily stressors for which smoking is seen as a means of coping

• lack of support for quitting among family and friends

• unaware of, or having misconceptions about cessation services

• lower levels of confidence in their ability to stop smoking

• regarding smoking as their ‘only pleasure

• specific marketing by tobacco companies

Effective strategies targeting disadvantaged groups

Population Wide

• Tobacco price increases, emotional advertisements,

increasing TV advertising and the extending of

smoke-free policies from restaurants to pubs have a

strong impact on smokers in lower SES groups

• Population-wide strategies reduce uptake and

experimentation of smoking among all adolescents,

but in particular adolescents from low SES

• While population-based tobacco control approaches

have demonstrated effectiveness among smokers

from low socio-economic groups, there is increasing

recognition that more targeted strategies are required

to reach the most disadvantaged population groups.

Community- based interventions

• integrate smoking cessation support in social and

community organisations already working with

disadvantaged groups decreases smoking

• Review and revise organisational policies, supporting

staff to quit, change practices to de-normalise

smoking, make more active quit support for clients

part of routine care, and change systems to record

and monitor smoking status

• Applied in non-government and government social

and community services with clients with smoking

rates, e.g. prisons, mental health facilities, drug and

alcohol and family services, and homeless shelters

Improve access to cessation aids

• Encourage better use of existing services and

treatments by low income groups

• Quitting medications when subsided or free, are

increasingly used by disadvantaged smokers if easily

accessible

• Key elements of effective cessation approaches with

disadvantaged population groups include: a non-

judgemental, holistic and empowering approach;

provision of social support; flexibility and

accessibility; and well trained staff

Financial Incentives

• Financial incentives have been used in US and UK as smoking

cessation initiatives to encourage participation and to support

the quitting process including rewarding cessation

• Increased quit rates among pregnant women in disadvantaged

groups (increasing abstinence more than three-fold)

• Other areas to explore further include:

– how to implement financial incentive schemes for promoting

smoking cessation within the Australian context

– the merits of cash payments versus payments in kind (e.g. grocery

vouchers)

– the most effective type and size of incentives, maintaining

incentives to achieve cessation in the long term, and efficacy in

different population groups

Social and Economic Policy support

Macro level policies that

– reduce poverty

– enhance family functioning

– reduce childhood adversity

– improve housing

– provide access to quality education

– provide access to stable employment

have an impact on smoking prevalence as they

reduce the negative social conditions that are

associated with higher smoking rates and

Research

Need specific research on

disadvantaged groups because

population surveys will not be

sensitive enough to provide

evidence of their needs.

Obesity

• Adult obesity rates in Australia have tripled in 30 yrs.

• In addition to the obese, more than 1 in 3 Australian

adults were overweight in 2007-08

• The prevalence of overweight and obesity combined

was 61% (3.9 million Australian adults are obese and

an additional 5.8 million people are overweight.)

• Overweight and obesity are more common in people

of lower socioeconomic status

• 66% of adults in the most disadvantaged social

groups are overweight or obese, compared with 56%

of adults in the least disadvantaged groups

• Overweight and obesity are also more common in

inner regional areas of Australia (56-60% of adults in

2004-05) than in major cities (52%)

Obesity and disadvantaged groups

Obesity is more prevalent among:

– Australians in lower socioeconomic groups

– people living in rural and remote areas

– Indigenous Australians

Affordable access to healthy foods and

opportunities to engage in physical activity are

major contributors

The development and implementation of specific

interventions targeting the social determinants of

health in these groups is key to addressing this

clustering of risk factors

Issues of Equity in obesity and

alcohol

• Low income groups have a greater burden of diet-

related chronic disease than people of higher SES

• A food tax is likely to be regressive for low income

households.

• With tobacco taxes those on low incomes are more

responsive to price increases

• If this holds for food products, low income

households could benefit more from food tax.

• Also incorporating subsidies (e.g. for fresh fruit and

vegetables) into a tax design to support those on low

incomes may help to combat the impact of a tax on

unhealthy foods and may result in higher

consumption of healthier foods such as fruit and

vegetables.

Conclusions

• Chronic disease risk factors need to be

addressed by lifestyle changes in lower SES

groups

• This requires both community and government

policy approaches