Social determinants of tobacco use: Towards an equity lens approach
More details
Hide details
The Johns Hopkins University, Advanced Academic Programs (AAP), Baltimore, USA
Alexios-Fotios A. Mentis   

The Johns Hopkins University, Advanced Academic Programs (ΑΑP), 3400 North Charles Street –Wyman Park Building S – 612, 21218 Baltimore, MD, United States
Publication date: 2017-03-02
Submission date: 2016-08-24
Final revision date: 2017-02-02
Acceptance date: 2017-02-07
Tob. Prev. Cessation 2017;3(March):7
Tobacco is the only commercial product that eventually kills nearly half of all long-term users. The prevalence of tobacco use is disproportionately high in lower socioeconomic strata and vulnerable groups (such as adolescents) within and across countries. Given its highly addictive nature, tobacco use perpetuates poverty and loss of opportunities, thus undermining the UN Sustainable Development Goals. Moreover, by shaping the national and international context, globalization and governance impact on the tobacco epidemic and underlying disparities. Therefore, socio-economic gradients, which influence predisposition to tobacco uptake and cessation, must be confronted. Here I argue that tobacco prevention and control must be addressed through a lifelong, equity lens approach. This approach describes the essential need for every individual to have equal access to informative prevention and cessation services independent of income, occupational status, social stratum, or residence. I also contend that rather than being occupied with “research on research”, the focus should shift to how to practically implement the existing accumulated, cogent body of scientific evidence in a societally equitable manner. Finally, in line with the core dilemma of “who really governs the policies that shape our health?” raised by the WHO’s Director General, it is time for civil society either on its own or in partnership with local authorities to formulate policies that implement the “health for all” imperative rather than the currently dominant “wealth for some”.
World Health Organization: Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control on the protection of public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry. 2008a. Geneva: World Health Organization.
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al: A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012, 380 (9859): 2224-60. doi: 10.1016/S0140-6736(12)61766-8.
World Health Organization: WHO report on the global tobacco epidemic, 2013a: enforcing bans on tobacco advertising, promotion and sponsorship. 2013a. Geneva: World Health Organization, Pages 38-41. 2013.
Jha P, Peto R, Zatonski W, Boreham J, Jarvis MJ, Lopez AD: Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. Lancet 2006, 368(9533): 367-70. doi: 10.1016/S0140-6736(06)68975-7.
Mathers CD, Loncar D: Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006, 3(11): e442. doi: 10.1371/journal.pmed.0030442.
Asma S, Mackay J, Song SY, Zhao L, Morton J, Palipudi KM, et al.: The GATS Atlas. 2015. CDC Foundation, Atlanta, GA.
King BA, Mirza SA, Babb SD: GATS Collaborating Group. A cross-country comparison of secondhand smoke exposure among adults: findings from the Global Adult Tobacco Survey (GATS). Tob Control 2013, 22(4): e5. doi: 10.1136/tobaccocontrol-2012-050582.
Warren CW, Jones NR, Peruga A, Chauvin J, Baptiste JP, Costa de Silva V, el Awa F, Tsouros A, Rahman K, Fishburn B, Bettcher DW, Asma S: Centers for Disease Control and Prevention (CDC). Global youth tobacco surveillance, 2000-2007. MMWR Surveill Summ 2008, 57(1): 1-28. pmid: 18219269.
Bircher J, Kuruvilla S: Defining health by addressing individual, social, and environmental determinants: New opportunities for health care and public health. Journal of Public Health Policy. 2014, 35(3): 363-86. doi: 10.1057/jphp.2014.19.
Garrett BE, Dube SR, Babb S, McAfee T: Addressing the social determinants of health to reduce tobacco-related disparities. Nicotine & Tobacco Research 2015, 17(8):892-7. doi: 10.1093/ntr/ntu266
Kunst A, Giskes K, Mackenbach J: Socio-economic Inequalities in Smoking in the European Union: Applying an Equity Lens to Tobacco Control Policies: for the EU Network on Interventions to Reduce Socio-economic Inequalities in Health. 2004. Erasmus Medical Center Rotterdam.
World Health Organization: Systematic review of the link between tobacco and poverty. 2011. Geneva: WHO. Pages: 1-10, 21-34, 47-142. Geneva: World Health Organization.
Brian K: OECD Insights From Aid to Development: The Global Fight against Poverty: The Global Fight against Poverty. 2012. OECD Publishing.
Arora M, Tewari A, Tripathy V, Nazar GP, Juneja NS, Ramakrishnan L, Reddy KS: Community-based model for preventing tobacco use among disadvantaged adolescents in urban slums of India. Health Promotion International 2010, 25(2): 143-152. doi: 10.1093/heapro/daq008.
Marmot M, Friel S, Bell R, Houweling TA, Taylor S, & Commission on Social Determinants of Health: Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet 2008, 372(9650): 1661-1669. doi: 10.1016/S0140-6736(08)61690-6.
Farrelly MC, Evans WN, Sfekas AE: The impact of workplace smoking bans: results from a national survey. Tobacco Control 1999, 8(3): 272-277. PMCID: PMC1763942.
Hobbs WR, Burke M, Christakis NA, Fowler JH: Online social integration is associated with reduced mortality risk. Proceedings of the National Academy of Sciences. 2016, 113(46): 12980-4. doi: 10.1073/pnas.1605554113.
Kim DA, Benjamin EJ, Fowler JH, Christakis NA: Social connectedness is associated with fibrinogen level in a human social network. Proc. R. Soc. B 2016, 283: 20160958. doi: 10.1098/rspb.2016.0958.
Greaves L, Hemsing N: Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure. Drug Alcohol Depend 2009, 104 Suppl 1: S121-30. doi: 10.1016/j.drugalcdep.2009.05.001.
World Health Organization: Gender, women and the tobacco epidemic. 2010a. Geneva: World Health Organization.
Okoli C, Greaves L, Fagyas V: Sex differences in smoking initiation among children and adolescents. Public Health 2013, 127(1): 3-10. doi: 10.1016/j.puhe.2012.09.015.
Madeley J: Big business, poor peoples: the impact of transnational corporations on the world's poor. 1999 Palgrave Macmillan.
Graham H, Der G: Patterns and predictors of tobacco consumption among women. Health Educ Res 1999, 14(5): 611-8. PMID: 10510069.
Thrift AP, Nancarrow H, Bauman AE: Maternal smoking during pregnancy among Aboriginal women in New South Wales is linked to social gradient. Australian and New Zealand Journal of Public Health 2011, 35(4): 337-342. doi: 10.1111/j.1753-6405.2011.00728.x.
Action on Smoking and Health: “Tobacco and the Developing World” Fact sheet. August 2015. In: (Accessed 14 January 2016).
Toll BA, Ling PM: The Virginia Slims identity crisis: an inside look at tobacco industry marketing to women. Tob Control 2005, 14(3): 172-80. doi: 10.1136/tc.2004.008953.
World Health Organization: Sifting the evidence: Gender and tobacco control. 2007. Geneva: World Health Organization, passim.
World Health Organization: Health for the world’s adolescents: a second chance in the second decade: summary. 2014a. Geneva: World Health Organization.
Kokkevi A, Fotiou A, Kanavou E, Stavrou M, Richardson C: Smoking, alcohol, and drug use among adolescents in Greece – 2015 update and secular trends 1984 – 2015. Archives of Hellenic Medicine 2016, 33(2): 249-257.
Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M: Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Social Science & Medicine 2008, 66(6): 1429-1436. doi: 10.1016/j.socscimed.2007.11.024.
Harakeh Z, de Looze ME, Schrijvers CT, van Dorsselaer SA, Vollebergh WA: Individual and environmental predictors of health risk behaviours among Dutch adolescents: the HBSC study. Public Health 2012, 126(7): 566-73. doi: 10.1016/j.puhe.2012.04.006.
Askitopoulou V: “Supporting students to say no to smoking”. In Round Table: “Smoking? Not for us!. A holistic school-based program to prevent tobacco use and addiction”. Proceedings of the “6th International Congress on Brain and Behaviour”. February 2014, Thessaloniki.
World Health Organization: Bollywood: victim or ally, a study on the portrayal of tobacco in Indian cinema. 2013b. Geneva: World Health Organization.
World Health Organization: Global progress report on implementation of the WHO Framework Convention on Tobacco Control. 2012. Geneva: World Health Organization.
Reddy KS, Yadav A, Arora M, Nazar GP: Integrating tobacco control into health and development agendas. Tob Control 2012, 21(2): 281-6. doi: 10.1136/tobaccocontrol-2011-050419.
Mentis AFA: Child migration: from social determinants of health to the development agenda and beyond. Medicine, Conflict and Survival 2016, 21:1-7.
Best CM, Sun K, de Pee S, Bloem MW, Stallkamp G, Semba RD: Parental tobacco use is associated with increased risk of child malnutrition in Bangladesh. Nutrition 2007, 23(10): 731-738. doi: 10.1016/j.nut.2007.06.014.
Mentis AFA: To What Extent Are Greek Children Exposed to the Risk of a Lifelong, Intergenerationally Transmitted Poverty? Poverty & Public Policy 2015, 7(4): 357-381. doi: 10.1080/13623699.2016.1258806.
Norman RE, Carpenter DO, Scott J, Brune MN, Sly PD: Environmental exposures: an underrecognized contribution to noncommunicable diseases. Reviews on Environmental Health 2013, 28(1): 59-65. doi: 10.1515/reveh-2012-0033.
Sly PD, Neira M, Collman G, Carpenter DO, Landrigan PJ, Van Den Berg M, Barriga FD, Ruchirawat M, Laborde A, Pascale A, Heacock M, Dalmau MT, Suk WA: Networking to advance progress in children’s environmental health. Lancet Glob Health 2014, 2(3): e129-30. doi: 10.1016/S2214-109X(14)70004-X
Gavidia T, Brune MN, McCarty KM, Pronczuk J, Etzel R, Neira M, Carpenter DO, Suk WA, Arnold RG, Ha EH, Sly PD: Children's environmental health—from knowledge to action. The Lancet 2011, 377: 1134-6. doi: 10.1016/S0140-6736(10)60929-4.
Eriksen M, Mackay J, Ross H: The tobacco atlas (No. Ed. 4). 2013. American Cancer Society.
World Health Organization: 2010 global progress report on the implementation of the WHO Framework Convention on Tobacco Control. 2010b. Geneva: World Health Organization.
McKnight RH, Spiller HA: Green tobacco sickness in children and adolescents. Public Health Reports 2005, 120(6): 602-605. doi: 10.1177/003335490512000607.
Mund M, Louwen F, Klingelhoefer D, Gerber A: Smoking and pregnancy—a review on the first major environmental risk factor of the unborn. International Journal of Environmental Research and Public Health 2013, 10(12): 6485-6499. doi: 10.3390/ijerph10126485.
Campaign for Tobacco-free Kids: Press releases for 2001. In: (Accessed 11 January 2016).
Dixon A: The economics of tobacco and tobacco control, a development issue. In: (Accessed 15 January 2016).
Taylor A, Chaloupka FJ, Guindon E, Corbett M: The impact of trade liberalization on tobacco consumption. Tobacco control in developing countries 2000, 343-64.
Mamudu HM, Hammond R, Glantz S: Tobacco industry attempts to counter the World Bank report curbing the epidemic and obstruct the WHO framework convention on tobacco control. Social Science & Medicine 2008, 67(11): 1690-1699. doi: 10.1016/j.socscimed.2008.09.062.
Bettcher D, Subramaniam C, Guindon E: Confronting the tobacco epidemic in an era of trade liberalization. 2001. Geneva: World Health Organization.
Fooks GJ, Gilmore AB: Corporate philanthropy, political influence, and health policy. PLoS One 2013, 8(11): e80864.
Amon JJ, Buchanan J, Cohen J, Kippenberg J: Child labor and environmental health: government obligations and human rights. Int J Pediatr 2012, 2012: 938306. doi: 10.1155/2012/938306.
Human Rights Watch: World Report 2014. 2014. In: (Accessed 10 January 2016).
United States Department of Labor: 2014 Findings on the Worst Forms of Child Labor. In: (Accessed 10 January 2016).
The Guardian: Child labour: the tobacco industry's smoking gun. 2011. In: (Accessed 11 January 2016).
Plan International: Malawi child tobacco pickers' '50-a-day' habit. 2009. In: (Accessed 11 January 2016).
Beaglehole R, Yach D: Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. The Lancet 2003, 362(9387): 903-908. doi: 10.1016/S0140-6736(03)14335-8.
McCoy RS: So-called benefits of tobacco industry debunked. 1996. Utusan Konsumer, Mid-July.
Zhong F, Yano E: British American Tobacco’s tactics during China's accession to the World Trade Organization. Tob Control 2007, 16(2): 133-7. doi: 10.1136/tc.2006.018374.
Hirschhorn N: Corporate social responsibility and the tobacco industry: hope or hype? Tobacco Control 2004, 13(4): 447-453. doi: 10.1136/tc.2003.006676.
Palazzo G, Richter U: CSR business as usual? The case of the tobacco industry. Journal of Business Ethics 2005, 61(4): 387-401. doi: 10.1007/s10551-005-7444-3.
Ulucanlar S, Fooks GJ, Gilmore AB: The policy dystopia model: An interpretive analysis of tobacco industry political activity. PLoS Med 2016, 13: e1002125. doi: 10.1371/journal.pmed.1002125.
Zeltner T, Kessler DA, Martiny A, Randera F: Report of the Committee of Experts on Tobacco Industry Documents. 2000. Geneva: World Health Organization.
Warner KE: The economics of tobacco: myths and realities. Tobacco control 2000, 9(1): 78-89. doi:10.1136/tc.9.1.78.
Chaloupka FJ, Yurekli A, Fong GT: Tobacco taxes as a tobacco control strategy. Tobacco Control 2012, 21 (2), 172-180. doi: 10.1136/tobaccocontrol-2011-050417.
World Health Organization: MPOWER: a policy package to reverse the tobacco epidemic. 2008b. Geneva: World Health Organization.
World Health Organization: 2014 Global progress report on implementation of the WHO Framework Convention on Tobacco Control. 2014b. Geneva: World Health Organization.
Tobacco control for all? The Belgian case
Pierre BIZEL
Tobacco Prevention & Cessation
Precision Medicine and Global Health: The Good, the Bad, and the Ugly
Alexios-Fotios A. Mentis, Kleoniki Pantelidi, Efthimios Dardiotis, Georgios M. Hadjigeorgiou, Efthimia Petinaki
Frontiers in Medicine