Balancing efficiency and equity in addressing tobacco-related disparities

Similar to other health risks, tobacco use and exposure are not equally distributed throughout the population of Ontario. As in many jurisdictions, smoking is concentrated among those with less income, lower educational attainment, and those who work in blue-collar industries. Aboriginal people are more likely to smoke than non-Aboriginals. Importantly, such tobacco-related disparities appear to be growing.

In this study, we distinguish efficiency from equity in establishing priority populations. Efficiency relates to maximizing outcomes in relation to effort and resources expended. It is addressed by optimizing the mix of interventions targeted at those populations with the highest burden and those with the greatest risk of tobacco use and exposure. Equity relates to what is considered fair or just, and necessitates an assessment of values and principles, which are then applied in an analysis of all groups, regardless of their level of burden or risk. Trade-offs between efficiency and equity are necessary.

Using these concepts, we identify priority populations in Ontario, and describe their burden and risk of tobacco use and exposure. We identify populations that may be missed by interventions intended to reduce tobacco use and exposure in the general population. Finally, we present existing evidence to support targeted interventions for priority groups where the issue of equity is an important consideration. Areas where further research is required are highlighted.

We conclude with a discussion of strategies to determine how to best combine general and targeted interventions to achieve the dual goals of improving population health and reducing health inequities.