Lifting the smoke screen on economic inactivity

Across Europe, governments are increasingly preoccupied with the challenge of economic inactivity, defined by the International Labour Organisation as the condition of not being in, seeking, or available for work.¹ Shaped by regional disparities in labour market demand, productivity and economic growth, prevalence is unequally distributed across places and populations, reflecting entrenched socioeconomic inequalities in Europe's most disadvantaged regions.² Health and health care inequalities are significant risk factors for labour market absence with long-term conditions the leading cause of economic inactivity in the G7.³ In this issue, Jackson et al.⁴ foreground the challenge of health-related economic inactivity (HREI), unpacking the complex bi-directionality of intersections between behaviours, structural exclusion and health outcomes by focussing on a modifiable risk factor: tobacco smoking.

Using the UK as a case study, one of few European nations where prevalence of economic inactivity has not returned to pre-pandemic levels,² the authors offer new insight into the interplay between proximal behaviours and distal structural determinants of health inequalities that shape labour market participation and exclusion. The relationship between the public's health and economic productivity is well understood.⁵ Jackson et al. extend this beyond the costs of health care and premature morbidity to flag the economic consequences of risky behaviours and their implications for better understanding HREI.

Socioeconomically disadvantaged populations, already disproportionately exposed to health and health care inequalities, are far more likely to experience HREI,⁶ resulting in negative health outcomes, with accompanying impact on community wellbeing and regional economic growth. Addressing the latter provides powerful political motivation for tackling economic activity generally, and HREI specifically.⁷ Using data from the Smoking Toolkit Study (STS) Jackson et al. demonstrate that, despite long-term declines in smoking prevalence in the general population, tobacco use continues to disproportionately impact socioeconomically deprived groups. Regression modelling illuminates that the doubling of HREI since 2013 has been most pronounced amongst current smokers; with prevalence higher, and absolute increases over time larger. Smoking must be understood both as a symptom and a driver of inequalities, a causal mechanism through which disadvantage is deepened.

Behavioural vulnerability and structural disadvantage intersect to entrench health inequalities in already marginalised populations.⁴ For example, chronic illness and mental health conditions, the leading causes of HREI, are both more prevalent in populations with higher rates of smoking. Here, smoking functions as a coping mechanism in the context of stress, pain, isolation and poor mental health, conditions exacerbated by long-term absence from the labour market. Further, the economically inactive experience greater social isolation with fewer incentives to quit. Smoking is simultaneously a consequence of marginalisation and a barrier to labour market engagement, reinforcing a cycle of poor health and economic marginalisation.

Jackson et al.'s prognosis is optimistic. The decline of economic inactivity with longer duration of smoking cessation suggests that targeted interventions could play a meaningful role in arresting and reversing upwards trends in HREI. For policymakers grappling with the economic and social consequences of increasing worklessness, they posit a compelling proposition; tackling inactivity is not only an economic imperative, nor is addressing entrenched smoking patterns a standalone public health concern. Rather, understanding how risky health behaviours function as both outcomes and determinants of health inequalities, and in turn labour market participation, is essential to addressing inequalities that widened during the COVID-19 pandemic. Recent UK policy programmes have huge potential for impact here.⁷

Reducing HREI requires a whole society approach sensitive to the interdependence of behavioural, ecological and systemic determinants of health. When framed as part of broader strategies for economic inclusion and the promotion of health equity, effective smoking cessation targeted at high-risk, low-income groups could be a powerful lever for change. While the STS offers vital insights into prevalence and patterns, its status as a standalone survey limits the ability to examine complex socioecological interdependencies characteristic of HREI. Linking STS with existing datasets (e.g., Understanding Society⁸) could illuminate how smoking interacts with illness, deprivation, place and work, providing valuable insight into behavioural and structural determinants whilst supporting political action that goes beyond traditional silos, supporting investment in interventions that are as much about health and wellbeing as they are economic participation.⁵ Recognising smoking as both a consequence of socioeconomic deprivation and a contributor to long-term ill health reframes it as a key part of the puzzle in reducing HREI. New UK policy programmes reflect this⁷ signalling a welcome shift towards whole-system approaches that treat achieving health equity and economic resilience as mutually reinforcing goals.

Contributors

Both authors contributed equally to the writing and editing of this commentary.

Declaration of interests

There are no conflicts of interest.