This section sets out inequalities in the health of young people and adults of working age. It summarises the evidence which we have concluded indicates areas for future policy development, and the benefits which may result from such policies. Many recommendations given already will apply to this group. In particular, work is an important determinant of health inequalities at this stage of the life course.

We recommend policies which improve the opportunities for work and which ameliorate the health consequences of unemployment (recommendation 8).

We recommend policies to improve the quality of jobs, and reduce psychosocial work hazards (recommendation 9).

Our additional recommendations relate to preventing suicide, particularly in young men and people who are known to be mentally ill, and promoting the adoption of healthy lifestyles.

Preventing suicide

Inequality
Suicide is more common in men than in women, and in lower socioeconomic groups. In 1996 the rates were three times higher for males than females. The highest rates are for men aged 25-44 and those over 75 years25. In 1991-1993 (the most recent data available by social class) in England and Wales, mortality from suicide for men was 4 times greater in social class V than in social class I29. The international literature consistently shows higher rates of suicide in young south Asian women, whilst lower rates are found in African Americans and African Caribbeans356. The overall age-standardised mortality rate for suicide has fallen by nearly a half in women over the last 20 years, but has hardly changed for men. This hides the information that over the same period, for men under 44, there has been a rise of 20-30 per cent whereas for men aged 45 and over there has been a fall of about the same magnitude32.

Evidence
Suicide is associated with unemployment, alcohol and substance misuse, imprisonment, and mental disorder357. Up to half of all people who commit suicide have a history of self-harm, and up to 1 per cent of people who self-harm go on to kill themselves358-360. People who deliberately self-harm are also likely to have problems with a relationship, employment, education, alcohol, substance misuse, and/or finances361.

Policies to prevent suicide include those aimed at the causes of social exclusion which may lead to suicide. These include: social support for parents (recommendation 23); pre-school education (recommendation 5); the development of "life skills" and the prevention of alcohol and substance misuse (recommendation 6); provision of adequate housing (recommendation 10, 11 and 12); the relief of poverty and reduction of unemployment (recommendation 8); the promotion of healthy workplaces (recommendation 9); and policies which promote social cohesion.

The association of suicide with existing mental illness suggests that policies for the care of young people with mental illness also provide opportunities for the prevention of suicide. About a quarter of those who kill themselves have been in contact with specialist mental health services in the year before their deaths362. A recent review on the promotion of mental health in high-risk groups reinforces the role of the primary health-care team both in identifying and co-ordinating the management of people at high risk363. Community mental health teams may be more effective than non-team standard care in preventing suicide in those who are already severely mentally ill364. Both types of team, which may have considerable overlap, need to ensure effective working between different disciplines and agencies363. An important component of the work of such teams is to address all the needs of the patient, including employment, housing and social support. Furthermore, particular strategies may be required to meet the needs of young people who either cannot or do not choose to access current services. These include people who default from follow up, absent themselves from school, or are in prison or young offenders' institutions.

Benefit
Most policies recommended here are aimed at the improvement of socioeconomic and living conditions, and social cohesion. They will have many benefits in addition to their contribution to the prevention of suicide.

24. We RECOMMEND measures to prevent suicide among young people, especially among young men and seriously mentally ill people.

Promoting healthier lifestyles

Health related behaviour is an important determinant of health and inequalities in health. However, the reasons why individuals adopt one form of behaviour rather than another are complex. They include the influence of earlier experience, including that as a very young child, the social and economic environment, work or school, and the cultural milieu, as well as characteristics specific to the individual. Furthermore the effects of health related behaviour or its consequences differ between individuals and between groups, depending on their susceptibility to these influences. For example the effect of a high body mass index in adult life on blood pressure is greater in people who were of lower birthweight301.

Thus, policies designed to change health related behaviour need to act at different levels, and to accept that behaviour change, for instance in the changing of children's dietary habits, may take some time to become apparent. The Inquiry considers that, as with inequalities in health in general, inequalities in health related behaviours need to be approached on a broad front considering both "upstream" and "downstream" policies, and policies which cover both short and longer-term benefits. This section sets out inequalities in health related behaviour and the evidence which we have concluded indicates areas for future policy development. Many of the more "upstream" policies in this area have been considered earlier in this report, and are cross-referenced. However, we wish to emphasise that these "upstream" policies are of crucial importance in reducing inequalities in health related behaviour. Furthermore, we consider that policies aimed at changing health related behaviour should avoid attaching blame or stigma to individuals or groups. Thus our recommendations are based on the principles of increasing information and choice to individuals and communities, and enabling them to make healthy choices365.

Promoting sexual health

Inequality
Men and women from manual households have a median age at first intercourse about 2 years lower than for those from social class I households. Black young people are more likely to have first intercourse under the age of 16 than white or Asian young people. The proportions with first intercourse under the age of 16 are 26 per cent for Black men, and 10 per cent for Black women, compared to 19 per cent and 8 per cent for young white people and 11 per cent and 1 per cent for young Asian people366.

Under-age conception rates for places within Britain are highly correlated with indices of deprivation, with high rates in areas which are deprived260. However, the relatively small number of events makes further analysis difficult. There is a fourfold difference between the health authorities with the highest and lowest rates, and large differences between one time period and another.

Evidence
For many young women, pregnancy and motherhood are positive and welcomed experiences without long term negative outcomes. However, compared to women aged 20 to 35 years, teenage mothers and their children are at higher risk of experiencing adverse health, educational, social and economic outcomes130. Approximately half of the pregnancies in under 16 year olds and a third of those in 16-19 year olds are terminated260. These terminations, along with miscarriages, can also have an adverse effect on the health of teenagers.

The risk of teenage pregnancy is increased in association with a number of social, socioeconomic and individual factors, many of which are more common in people experiencing disadvantage - for example, low educational attainment, poor housing. Particularly at risk are the daughters of teenage mothers, young people "looked-after" by the local authority or leaving care, school non-attendees - due to truancy or exclusion - and homeless or runaway teenagers. Although it is difficult to establish cause and effect, it is possible that reducing inequalities in some of these socioeconomic risk factors - for example, poverty or educational attainment - would reduce inequalities in unwanted teenage pregnancy130.

More specific interventions to promote sexual health focus on education and provision of appropriate and sensitive contraceptive services130. Features associated with successful sex education programmes include: timing, which should precede the onset of sexual activity; a combined approach to education and information about the provision of contraception; integration with psychological approaches, and with other life management skills; context, emphasising responsible and caring relationships and a recognition of social influences and pressures; a focus on specific aims, such as delayed intercourse and safe intercourse; and the tailoring of the programmes to the needs of the group they are intended to serve129,130.

Most of the evaluated programmes have focused on addressing individual factors associated with teenage pregnancy, rather than the associated social and economic factors. No studies have specifically focused on reduction of inequalities in risk of outcomes. The role of sex education is discussed earlier in the text supporting recommendation 6 on the development of health promoting schools.

The role of parents in sex education also needs to be recognised. Under the age of about 16 years young people generally report that their parents should be the main source of information about sex but in practice this is often not the case. Appropriate means to help parents increase their skills and confidence in sex education need to be developed. The media also have an important role to play in providing information and influencing the climate of opinion367.

Provision of contraceptive services to teenagers is highly cost effective, saving £377 and £466 per unwanted pregnancy avoided for clinic and general practice provision respectively, even if only the resource consequences for the NHS of pregnancy are taken into account. The savings are much greater if the longer term health gains are considered130. However, teenagers may lack information about contraceptive use or availability. A recent review of the literature found a lack of UK evidence on the effectiveness or cost effectiveness of different approaches to the delivery of contraceptive services to young people. Descriptive studies suggest that services should be based on a local needs assessment and ensure accessibility and confidentiality. Clinic-based settings may be used more than those in primary care. Because of the nature of teenagers' sexual activity, which can be unplanned and sporadic, provision of emergency contraception is important. However, there is widespread public and professional misunderstanding of the use of emergency contraception, which may merit particular health education action130.

Interventions have not evaluated whether policies will preferentially promote sexual health and reduce unwanted teenage pregnancy rates in people experiencing disadvantage. Targeting of education on contraceptive provision - for example, by individual characteristics or by area - might be a way of reducing inequalities. Over half of teenage pregnancies continue to delivery. Policies and evidence on preventing the adverse health and social outcomes of teenage pregnancy are presented under recommendations 21 and 23.

Benefit
For more "upstream" policies, promotion of sexual health and prevention of unwanted pregnancy might be only some of many benefits. In general, sex education programmes have not been associated with increased sexual activity or its complications and some have been associated with delayed onset of sexual activity129,130. Sex education and appropriate contraceptive use are likely to decrease rates of sexually transmitted diseases and promote other aspects of sexual health. Prevention of unwanted teenage pregnancy will reduce the risks to the physical, mental and social health of the potential mother.

25. We RECOMMEND policies which promote sexual health in young people and reduce unwanted teenage pregnancy, including access to appropriate contraceptive services.

Encouraging physical exercise

Inequality
Levels of physical activity in men show a complex pattern with social class, with more men in lower social classes reporting physical activity as part of their occupation and more men in higher social classes reporting moderate or vigorous walking and leisure activity. In women there are similar gradients in walking and leisure activity and no clear pattern with occupational activity. People in lower socioeconomic groups walk more than those in higher groups but are less likely to describe their walking pace as brisk or fast. Inactivity, which may be a better predictor of obesity, is more common in lower social classes for both men and women35.

The proportion of men who are obese has risen from 13 per cent in 1993 to 16 per cent in 1996. For women the equivalent figures are 16 per cent and 18 per cent. Obesity is higher in the lower social classes in women, with 25 per cent in class V being classified as obese compared to 14 per cent in social class I and with intermediate proportions in the classes between I and V. In men, there are lower rates of obesity in social class I (11 per cent) but the higher rates in social class V (18 per cent) are similar to those in the remaining classes37. Rates of obesity and mean body mass index appear to be increasing for school-aged children368.

Evidence
Increased physical activity of moderate intensity is associated with lower overall mortality rates and decreased risks of mortality from cardiovascular disease, colon cancer and non-insulin dependent diabetes mellitus. Regular physical activity prevents or delays the development of hypertension, and reduces blood pressure in those with hypertension. These effects may be, in part, mediated by the fact that physical activity prevents weight gain and obesity. Physical activity also relieves the symptoms of depression and anxiety and is important in the prevention of osteoporosis. As these are common conditions, relatively small reductions in risk of them would result in significant gains in public health369-372.

Recommendations to promote moderate intensity exercise most commonly cite brisk walking as the mode of physical activity373. Walking is the most common form of physical activity across all socioeconomic groups, although both the number of journeys undertaken on foot and the annual average distance walked are decreasing236,259. Interventions where the mode of exercise being promoted is walking appear to be more effective than those that depend on attending a special facility to practice games or sports374. Walking should also be more accessible to those in lower socioeconomic groups, as it does not require costly equipment or training. In addition it can, theoretically, be incorporated into everyday routines, although in deprived areas, improved access to a safe and pleasant environment would be a necessary pre-condition. The provision of low-cost keep fit classes in existing local facilities, such as community centres or schools is one option.

Most interventions have been tested on white, middle-aged, well-educated men and women, and it is not known whether interventions would differentially benefit those in lower socioeconomic groups. The relative effectiveness of different types of intervention is largely unknown.

The evidence on encouraging walking and cycling and the safe separation of pedestrians and cyclists from motor vehicles is given in the text for recommendation 15. These policies may be particularly important in promoting exercise in children. Fear of accidents and harm is an important component in the increasing use of transport of children in cars, particularly to and from school. The promotion of physical activity, over and above participation in formal physical education, is one of the roles of health promotion within schools (see recommendation 6).

Benefit
Decreased levels of inactivity and increased physical activity should reduce and prevent obesity, cardiovascular disease and non-insulin dependent diabetes mellitus. As well as these health benefits, opportunities afforded by exercise might also lead to wider social networks and increased social cohesion.

Reducing tobacco smoking

Inequality
There is a higher prevalence of cigarette smoking in lower socioeconomic groups. In 1996, 29 per cent of men and 28 per cent of women smoked but this ranged from 2 per cent of men (11% of women) in professional occupations to 41 per cent men (36 per cent of women) in unskilled manual occupations. Amongst smokers, men and women in professional occupations smoke fewer cigarettes per week than those in unskilled manual occupations28. Furthermore, nicotine dependence is higher in people experiencing disadvantage, with higher plasma cotinine levels even after adjusting for the number of cigarettes smoked35,37. Not only do men and women in the lower groups have higher prevalence rates, they also have lower cessation rates. Since 1973 rates of cessation have more than doubled in the most advantaged groups, from 25 per cent to over 50 per cent. In the least well off groups, there has been a very limited increase in cessation rates from 8 to 9 per cent cessation in 1973 to 10 to 13 per cent in 1996375.

Evidence
Smoking is an important component of differences in mortality between social classes376. In the United Kingdom, more cancer deaths can be attributed to smoking tobacco than to any other single risk factor. In 1995, smoking was estimated to account for more than 30,000 deaths from lung cancer, and a further 16,000 deaths from cancer of other sites, notably the oesophagus, bladder, stomach, mouth and throat, contributing to approximately one third of the mortality of cancer as a whole377. Smoking is also an important cause of chronic obstructive lung disease, coronary heart disease, stroke and aortic aneurysm. Furthermore, smoking damages the health of non-smokers. A recent review concluded that passive smoking causes lung cancer and coronary heart disease in adult non-smokers, and respiratory disease, sudden infant death syndrome, middle ear disease and asthmatic attacks in children320.

For the population as a whole, tobacco consumption falls when the real price of tobacco rises378-380. The price elasticity of cigarettes is higher among young people. Studies in the United States and Canada indicate that young people's intention to smoke and their uptake of smoking are highly price-sensitive381-386. An important factor in explaining the greater effect of price on young people is that most are not habitual, nicotine dependent, smokers. Price rises can therefore be an effective way of preventing the onset of regular smoking in adolescence. With very few smokers taking up regular smoking after the age of 20, price can clearly have a longer-term impact on the prevalence of smoking and thus on inequalities in smoking-related disease.

However the real price of tobacco has a disproportionate effect on the living standards of Britain's poorest households, for whom expenditure on tobacco is a larger proportion of disposable income387. Households in the lowest tenth of income spend 6 times as much of their income on tobacco as households in the highest tenth278. Over 70 per cent of two-parent households on Income Support buy cigarettes, spending about 15 per cent of their disposable income on tobacco388. Approximately 55 per cent of lone mothers on Income Support smoke, smoking on average 5 packets of cigarettes per week327. Studies of the cost of meeting basic needs, which explicitly exclude spending on tobacco, indicate that Income Support levels are insufficient to secure a basic but adequate standard of living, especially if the households contain children65,78,81,84,85. Not surprisingly, therefore, low income households where the parents smoke are much more likely to be lacking basic amenities, including food, shoes and coats than non-smoking parents on Income Support388.

Although smoking prevalence has decreased overall, despite increases in the real price of tobacco, it has remained stable amongst people who are most disadvantaged375. A recent longitudinal survey of lone mothers found that living in severe hardship was the primary deterrent to quitting. This makes it unlikely that increasing the price of tobacco, and so decreasing disposable income and increasing hardship, will increase cessation rates in disadvantaged households327.

Advertising bans in Canada and New Zealand have reduced tobacco consumption. We note that the European Union Council of Ministers formally adopted the Directive to ban tobacco advertising and sponsorship in May 1998. Media advocacy and creation of unpaid publicity may not result directly in cessation but form the basis of public opinion on which other measures rest. Restrictions on smoking in public places or the workplace probably reduce consumption but the effects on cessation are undetermined. However, they may reduce the effects of passive smoking. Overall, evidence does not indicate which policies are the most effective in reducing inequalities320,380. The relatively stable rate of cessation in disadvantaged groups over the last 20 years suggests that simply intensifying current approaches is unlikely to sufficient.

The cultural and environmental barriers that disadvantaged people face in quitting smoking will take time to change. In the shorter term, a complementary strategy is to reduce nicotine dependence, which is likely to be stronger in disadvantaged smokers than amongst the affluent35,37.

Nicotine replacement therapy (NRT) has been shown to be an effective treatment aid, approximately doubling success rates from both brief and intensive treatments, and with evidence that its efficacy is maintained in real world settings389-393. It is not known whether it is preferentially effective in helping those who are disadvantaged to quit. Trials have found that NRT is effective in helping nicotine-dependent smokers to stop smoking390,393. Because there is a socioeconomic gradient in nicotine dependence, NRT may therefore have a differentially beneficial effect in smokers in lower socioeconomic groups. However, as it is currently sold at commercial rates over the counter, its price could prohibit its use amongst people on low incomes394. Preliminary evidence suggests better compliance and outcome when the smoker does not have to pay395. NRT could be made available on prescription or through other mechanisms which make it free to those who are least able to afford it394,396. NRT on prescription would also have the benefit of involving general practitioners in smoking cessation. Brief advice from a general practitioner is a highly cost effective method of promoting cessation of smoking, with cessation rates equivalent to rates achieved as a result of mass media campaigns, up to 5 per cent380. Community-based interventions and specialised smoking clinics are also effective settings in which to provide NRT390.

Benefit
Reduction in smoking would decrease the risk of smoking related diseases over a period of time and decrease the risks of passive smoking to companions in various settings. The relative differences in mortality by socioeconomic group are similar in smokers and non-smokers. However, given the higher mortality rate in smokers and the increased rates of smoking in lower socioeconomic groups, reduction in smoking in all socioeconomic groups will decrease the absolute difference in mortality rates between socioeconomic groups277.

Reducing alcohol-related harm

Inequality
Deaths from diseases caused by alcohol show a clear gradient with socioeconomic position, with an almost fourfold higher rate in unskilled working men compared to those from professional groups. In addition, alcohol is a contributory factor to deaths from accidents, which also show a pronounced socioeconomic gradient397.

Amongst people under the age of 30 years, there is little variation in consumption of alcohol by socioeconomic group. However problem drinking is twice as common in the poorest as in the most affluent, 17 per cent versus 8 per cent for men and 6 per cent versus 3 per cent for women. In older adults, a similar pattern exists for men. In older women consumption is greater in the affluent, but there is no socioeconomic gradient in problem drinking, and poor women are more likely than the affluent to report being drunk35. Higher levels of consumption of alcohol have been consistently observed in some deprived groups, such as unemployed people398-400 and those who are homeless401,402. These observations suggest that the pattern of drinking influences alcohol-related health inequalities. Problem drinking is associated with delinquency, criminality and violence, including domestic violence and child abuse. The degree to which health-damaging drinking patterns in young people persist into later life is unclear. Deprivation may contribute to the probability of continuing to drink in a hazardous fashion, and may also inhibit opportunities for positive changes in behaviour. Heavy drinking in people in higher socioeconomic groups may be less harmful than in lower socioeconomic groups because they are protected from harmful effects by better diet, housing, health care and other factors403.

Evidence
At a population level, there is a positive correlation between mean consumption and the prevalence of heavy drinking. This suggests that one mechanism to reduce problem drinking and thus alcohol-related harm, is to reduce mean consumption404. Overall population consumption is affected by price405-407. Increasing the price of alcohol may decrease consumption amongst low income problem drinkers but the effect of price elasticity on different groups has been little studied408,409.

Problem drinking in young people may be influenced by wider measures which support them and enhance their chances of employment and improved living conditions. Sensible drinking habits may be engendered in childhood and so be affected by interventions at school (see recommendation 6).

A reduction in the permitted level of blood alcohol concentration for driving from 80 to 50 mg/100 ml has been associated with reduced rates of alcohol-related accidents and risk behaviour in some countries410. The introduction of random breath testing is another option which may be a significant deterrent to drinking and driving410,411. The provision of adequate and affordable transport would assist in reducing the perceived need to drive after drinking.

People with alcohol-related problems who are disadvantaged in other ways, through having limited financial or social resources or being homeless, may have less access to appropriate treatment services for all their needs, including treatment of their alcohol- related health problems196-199. Recommendation 11 addresses this inequity.

Benefit
A decrease in problem drinking should reduce alcohol-related disease and accidents, as well as some types of anti-social behaviour.

26. We RECOMMEND policies which promote the adoption of healthier lifestyles, particularly in respect of factors which show a strong social gradient in prevalence or consequences. Specifically:

26.1 we recommend policies which promote moderate intensity exercise including: further provision of cycling and walking routes to school, and other environmental modifications aimed at the safe separation of pedestrians and cyclists from motor vehicles; and safer opportunities for leisure.

26.2 We recommend policies to reduce tobacco smoking including: restricting smoking in public places; abolishing tobacco advertising and promotion; and community, mass media and educational initiatives.

26.3 We recommend increases in the real price of tobacco to discourage young people from becoming habitual smokers and to encourage adult smokers to quit. These increases should be introduced in tandem with policies to improve the living standards of low income households and policies to help smokers in these households become and remain ex-smokers.

26.4 We recommend making nicotine replacement therapy available on prescription.

26.5 We recommend policies which reduce alcohol-related ill health, accidents and violence, including measures which at least maintain the real cost of alcohol.