Mouth cancer
gave a near two-fold increase risk. However, when we took into
account how much of these dif- ferences were explained by alcohol, smoking and diet, sig- nificance was diminished in all but education, with education conferring a 30 per cent increase risk independent of lifestyle. This finding was con- sistent for all cancer subsites – including mouth cancer. It was more prominent in UK and northern and eastern European centres compared to central and southern European centres. We also found, from the life
course of occupational histo- ries, that downward social mobility or being consistently in lower socioeconomic group, relative to a life-time in a high- er socioeconomic group gave an increased risk. So, the explanation for our
findings boil down to two path- ways: the ‘cause of the cause’ explanation – with low socio- economic circumstances influ- encing behaviour – and we have seen this; and the more ‘direct/ fundamental’ effects of socio- economic status, and we have observed this also. What was interesting was
that low educational attainment was the strongest socioeconom- ic risk factor. The explanations for this have yet to be fully unbundled, but education potentially: • reflects childhood socioeco- nomic circumstances
• influences position in society, social networks and income
Above: David (right) with Ralph Goodson of Heads2gether Patient Support Group
• advertising targeted to more deprived areas and groups
• unequal dissemination of smoking information and availability of smoking cessa- tion services
• social stresses, cultural differ- ences and norms. In conclusion, our study found:
• socioeconomic inequalities in mouth cancer risk are not totally explained by lifestyle risk
• education is the most power- ful of the socioeconomic factors
• affects access to healthcare services, health information and uptake
• determines values, attitudes, cognitive decision-making, and risky behaviours. We must also reflect that smoking and alcohol are social- ly patterned and have been described as social justice issues. While one could argue that
smokers in a sense choose to smoke, we know that this choice is effected by the unequal social circumstances in which they are made. Analysis of the liter- ature reveals important factors such as:
• further investigation into underlying biological processes is required, includ- ing the role of psychosocial stress. Finally, if I may, and given our location at the heart of political decision making, I would like to extend our research findings into some potential implications for policy and practice : 1 We need upstream action – by that I mean efforts to address the underlying socioeconom- ic determinants are required if we are to really tackle health inequalities. The ongoing debate about the fairness (or otherwise) of the public sector cuts in the recent com- prehensive spending review highlights some acknowledg- ment of this. The Marmot Review into tackling health inequalities needs to be implemented, but it looks like it may be ignored just as the Black Report was nearly 30 years ago.
2 Maintaining education – as a, if not the, top governmental priority – is essential, partic- ularly in these times.
3 Public health and preventive programmes or behavioural risk factors need to more explicitly acknowledge and be designed to take into account socioeconomic cir- cumstances.
4 Rather than target interven- tions to deprived communities, activities and services should be developed with communi- ties as full partners.
5 And finally, health services
need to further shift from a treatment to a preventive focus.
In these regards, there
remains some uncertainty about which direction policy is going with the coalition government. Health inequalities were con- spicuous by their absence from the initial coalition agreement. Health and wellbeing inequalities seem to be lost from the discourse around the gov- ernment’s spending review – where I would argue that the impact of the cuts should be viewed through this lens and health inequalities’ impact assessed. Moreover, health inequalities seem sidelined in the NHS White Paper. We need to follow the Dental
Health Foundation’s lead with shifting from Mouth Cancer Awareness to Mouth Cancer Action Month – we need more action. And for all the politicians
here, I leave you with a quote from George Orwell’s The Road to Wigan Pier, which I believe encapsulates the will required to tackle inequalities in health, including those we observe for mouth cancer : “Economic injustice will
stop the moment we want it to stop and no sooner, and if we genuinely want it to stop, the method adopted hardly matters.”
® David Conway is a Clinical Senior Lecturer in Dental Public Health at the University of Glasgow Dental School
Scottish Dental magazine 55
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