How are disparities in smoking highlighting the global issue of health inequality?

disparities in smoking
© Weerapat Kiatdumrong

C3 Collaborating for Health is working to make it easier for everyone to make healthier choices, and here, we learn why this is particularly important for smokers

Smoking is the leading cause of preventable deaths globally – killing more than eight million people each year worldwide – and is the biggest single cause of non-communicable diseases (NCDs) which include cardiovascular disease, cancer, chronic lung disease and diabetes. (1) In October 2020 Professor Chris Whitty, England’s Chief Medical Officer, predicted that by the end of that same year, at least as many people would have died from a smoking-related illness as COVID-19.

At C3 Collaborating for Health (C3), we seek to prevent NCDs by promoting three behaviour changes:

  • Improving diet.
  • Increasing physical activity.
  • Stopping smoking.

Through multi-sector collaboration, we work with communities to make it easier for everyone to make healthier choices, which we know is especially difficult for those living in disadvantaged communities. C3 is currently working with seven communities in the North of France and the South of England via an EU-funded project ASPIRE (Adding to Social capital and individual Potential In disadvantaged REgions). This multi-partner project aims to address the complex issues of obesity and unemployment, which frequently co-exist with smoking.

Addressing behavioural change

The need to address behavioural change so as to prevent NCDs has been given fresh impetus by the ongoing COVID-19 global pandemic and the established correlation between the severity of disease and existing long-term conditions such as hypertension and obesity – both metabolic risk factors for NCDs.

Indeed, the COVID-19 pandemic has brought the longstanding and global issue of health inequality into the mainstream media and has further shown the world that socially disadvantaged individuals continue to get sicker and die sooner than people in higher socio-economic groups because they are at greater risk of being exposed to harmful substances, (such as tobacco), have unhealthy diets, and access healthcare less frequently and less easily. (2) But sadly, health inequalities long predate the recent pandemic. In February 2021, the Lancet medical journal published an editorial to mark 50 years since the publication of Tudor Hart’s ‘Inverse Care Law’ (3) which states that “the availability of good medical care tends to vary inversely with the need for it in the population served.” (4) Drawing upon his experience working as a GP in London and more latterly a south Wales mining village, Dr Hart used the Inverse Care Law to describe the perverse relationship between the increased need for healthcare in socially disadvantaged populations who are least likely to receive it, compared to more advantaged populations, who demonstrate greater utilisation of healthcare services. (3)

The undisputed and incomparable harmful effects of the single behavioural risk factor that is smoking are universally acknowledged. Indeed, during community engagement projects in which we at C3 consult with communities about their health behaviours and choices, we are frequently informed by individuals that they know smoking is bad for them. Yet smoking levels are higher in disadvantaged communities worldwide, which is a testament to the highly addictive nature of nicotine in cigarettes. The power and strength of nicotine addiction cannot be overstated, it drives global sales of tobacco products and funds an enormously powerful and wealthy multi-billion-dollar industry: An industry that is knowingly profiting from ill health and death, and an industry that has,according to some evidence, specifically targeted disadvantaged communities. (5)

It is well evidenced that smoking rates are higher in individuals in low-paid and stressful jobs, those in routine and manual labour, the unemployed, and those with no formal qualifications. (6) The reasons for increased tobacco use in disadvantaged populations are many and complex. Factors include higher levels of tobacco dependency, social norms (e.g., an individual is more likely to smoke if they live with smokers), and social stressors associated with living with limited financial means such as unstable employment and insecure housing. The issue is by no means limited to the UK. Globally, tobacco use is highest in low- and middle-income countries (LMICs), where 80% of the 1.3 billion tobacco users worldwide reside. (7) Such countries are still recovering from infectious disease epidemics such as HIV, Malaria, TB, and now COVID-19. These are health challenges that resource-rich countries have had the luxury of mitigating for considerably longer. Addicted smokers in LMICs may be forced to choose between tobacco and education for their children or food for their families – a choice dominated and usually hard-won by their addiction to nicotine.

Lowering the use of tobacco

The global growth in tobacco use and the cross-border effects of global supply and demand triggered the formation of the WHO Framework Convention on Tobacco Control in 2005, (8) which aims to lower harmful tobacco consumption; reduce smoking rates in children; and counter the tobacco industry’s lobbying, advertising, and promotion activities. (9) But the high-risk behaviours of socially disadvantaged groups or tobacco industry lobbying, advertising or promotion are not solely responsible for generating billion-dollar profits. You may be investing, or have invested, in Big Tobacco without knowing it. Dr Bronwyn King, founder of Tobacco Free Portfolios and friend of C3 tells a sombre story in a 2017 TED talk viewed over three million times. Whilst working as a doctor in Australia, she witnessed the devastating effects of smoking when treating patients with lung cancer, many of whom had been smokers since childhood. It was during a routine meeting with a financial advisor that Dr King realised to her horror she had been investing in Big Tobacco via her compulsory pension – the very industry responsible for limiting the lives of most of her patients. This reckoning catapulted Dr King into action to advance the global transition to tobacco-free finance by convincing portfolio managers to divest from tobacco.

Dr Tedros Ghebreyesus, World Health Organization Director-General summed up the immeasurable harm and costs caused by smoking when he suggested: “If tobacco were a deadly virus, we would invest millions in a vaccine to prevent it, or, millions to treat it” – words that seem more powerful and resonant than ever as countries begin to reflect on their successes and failures after the biggest global health crisis for over a century.


(1) OECD/WHO (2020). Tobacco [Internet]. Health at a Glance: Asia/Pacific 2020: Measuring Progress Towards Universal Health Coverage,. 2020. Available from:

(2) WHO. Non-communicable diseases [Internet]. 2021 [cited 2021 May 17]. Available from:

(3) The Lancet. 50 Years of the Inverse Care Law. Lancet [Internet]. 2021;397(10276):767. Available from:

(4) Tudor Hart J. the Inverse Care Law. Lancet. 1971;297(7696): 405–12.

(5) Action on Smoking and Health. Smoking and Poverty [Internet]. 2019. Available from:

(6) ONS. Statistics on Smoking – England , 2018 [PAS] [Internet]. 2018 [cited 2021 May 18]. Available from:

(7) World Health Organization. Tobacco key facts [Internet]. 2020. Available from: /detail/tobacco

(8) World Health Organization. WHO framework convention on tobacco control [Internet]. World Health Organization. 2005. Available from: file:///Users/amandathieba/Downloads/9241591013.pdf

(9) Hoffman SJ, Poirier MJP, Rogers Van Katwyk S, Baral P, Sritharan L. Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: Quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling. BMJ. 2019;365.


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© 2019. This work is licensed under CC-BY-NC-ND.

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  • C3 Collaborating for Health

    C3 brings together different communities to create health changes that make it easier to stop using tobacco, improve diet and do more physical activity.

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