Dr Mark Ragg, a health and communications expert, believes the history of smoking among people with mental illness holds some lessons for those working to tackle Indigenous smoking, and also gives cause for optimisim.

He writes:

“David Thomas’ article is fascinating, as well as providing very good news. I’ve come recently to the issue of smoking in Indigenous populations after doing some work in smoking among people with mental illness, and have been struck by the similarities in approaches towards these two disadvantaged groups.

In both cases, there is a false belief that smoking is uniformly high and unchanging, leading to an almost nihilistic belief that nothing is possible. So if nothing is possible, nobody needs to act. And in both cases, smoking is excused by many health workers on grounds like ‘they have nothing better to do’ or ‘I don’t want to jeopardise our relationship by bringing up a difficult issue’.

There are certain things that clearly work to reduce smoking rates in populations – reducing the opportunities to promote smoking, reducing the opportunities for people to smoke, increasing the price and having health professionals give advice, support and medication such as nicotine replacement therapy when needed. Legislation, regulation, social marketing and specific health programs are all means to achieve these ends.

Certainly in people with mental health, and it seems in Indigenous populations, the problem has been that the basics have not been applied. People with mental illness have not had health professionals giving them advice and support. In fact, many people with mental illness are still told to smoke by their doctors.

But some progress is being made. In the US, psychiatrists have specific training programs in smoking cessation which are proving popular and effective, and similar approaches are being considered here.

In Australia, various health services are running smoking cessation programs for people with mental illness, and providing training for employees involved.

Croakey encourages bold predictions, so here’s one.

In 20 years time, policymakers and academics will look at smoking among people with mental illness, and among Indigenous people, and see that these high prevalences were a blip. A troubling time with severe health consequences, but a blip. Once these disadvantaged groups received the same resources and support as others, the problem began to recede.”

• Mark Ragg is director of the health and communications consultancy RaggAhmed and adjunct senior lecturer in the Sydney School of Public Health, University of Sydney.

Dr David Thomas, a senior research fellow at the Menzies School of Health Research in Darwin, reports:

“In March last year, the National Indigenous Health Equality Summit set a target of reducing Indigenous smoking prevalence by 2% every year.  It sounds great: so much Indigenous suffering would be avoided and so many early deaths averted.

Tobacco control became a big ticket item in Rudd and Roxon’s plans to ‘Close the Gap’, with millions committed in last March’s Indigenous Tobacco Control Initiative and millions more to come as part of their COAG initiatives.  But few would have really believed that the 2% target could be achieved: just aspirational slush like ‘no child will live in poverty’.

Back then, the hard truth was that Indigenous smoking prevalence had not changed whilst smoking was successfully falling in the rest of the population.  This was based largely on three large national Indigenous surveys performed by the Australian Bureau of Statistics in 1994, 2002, and 2004.  All other national survey data had tiny Indigenous samples, and so provided useless estimates.  Each of the ABS surveys reported that about 50% of Indigenous adults smoked, about double the Australian prevalence of smoking.

What most readers have overlooked is that the reports of these surveys used different age cut-offs and different definitions of smoking (daily or all current smokers).  This week in the International Journal for Equity in Health, I described the prevalence of current smoking amongst Indigenous adults aged 18 and over in each survey.

From 1994 to 2004 Indigenous smoking prevalence in non-remote Australia fell in parallel with the total Australian population (by 5.5% in men and 1.9% in women).  In remote Australia, smoking prevalence also fell amongst men (by 3.5%) and appears to have peaked in women.  These two different trends can be neatly explained by international research about the shape of smoking epidemics, with remote Indigenous Australia just at an earlier point in the predictable smoking epidemic curve than Indigenous peoples in non-remote Australia.

Also this week, the ABS released the first results of the fourth national Indigenous survey in this series.  Detailed comparisons are not yet possible, but they too have reported a drop in national Indigenous smoking, from 51% in 2002 to 47% in 2008.

Even though both of this week’s reports have some limitations, we can reasonably confidently say that Indigenous smoking prevalence is not resiliently static, as once thought.  The Indigenous smoking epidemic is not exceptional, and there is no need to entirely re-think and re-fashion tobacco control in this setting.  We can adapt what has been successful in Australia and elsewhere.

Reducing Indigenous smoking is no longer a seemingly impossible task.

Indigenous smoking was slowly falling before a cent of the new money was spent.  How fast it falls now the new money is starting to hit the ground will depend on how that money is spent.

We should feel emboldened by this week’s news.  We should no longer call ‘encouraging’ any future reduction in Indigenous smoking; we should expect a dramatic reduction, maybe even the fabled 2% annual reduction dreamed up last March.”

The advent of the Agency presents another predictable opportunity for a predictably boring debate about the “nanny state”, as per this segment from Richard Aedy and the Life Matters Team yesterday, featuring public health advocate Professor Mike Daube and individual choice advocate Julie Novak, from the Institute of Public Affairs. Incidentally, Mike Daube also spoke at a nanny state debate earlier in the year that I wrote about for Crikey.

It’s well and truely time that we put these nanny state debates to rest. They are SO last century and so unenlightening, especially when there is much else we could be talking about, including how many aspects of the modern environment encourage and support unhealthy behaviours.

The problem with the nanny state debate is that it keeps the discussion firmly focused on health as a function of individual behaviour, when it is much more useful and helpful to take an environmental health perspective.

Smoking rates fell because of changes – such as workplace smoking bans, advertising bans, increased taxes and prices, and changing social mores – which created an environment that made it easier for individuals to make healthy choices.

The other problem with focusing on Nanny is that it keeps the focus firmly away from where it is needed: looking at the contribution of powerful industries – food, alcohol etc – to poor health.

So next time anyone feels inclined to reach for a Nanny state debate, don’t bother. Nanny is now officially dead and buried. I hope.

Post Script: Now here’s a smart way to examine related issues (and no mention of Nanny either). Courtesy of the SMH’s Ross Gittins.

This one is called Cough N Rap

Click here to view the embedded video.

And, I don’t know about you, but this one just makes me want to dance… (if it doesn’t stop people smoking, it might at least get them moving…)

Click here to view the embedded video.

The clips (and there are more in a similar vein) are being disseminated via mobile phones in Arnhem Land by Miwatj Health, after receiving rave reviews at a recent local festival.

According to a Miwatj Health press release: Under the banner “Yaka Ngarali”, meaning No Smoking in Yolnu language, local family groups came up with the story lines led by Galiwin ‘ku musician Nigel Yunupingu of the band Saltwater. Up to 50 people had a hand in writing the songs and appearing in the videos.

It’s yet another reminder of the value of involving local communities in developing their own solutions to health problems….

He writes:

“The decision by the Preventative Health Taskforce to start with the soft policies is clearly a political one.

An evidence-based decision would have looked at the track record of self-regulation of food, alcohol and tobacco industries and seen that they serve the industries and not the public.

The Taskforce report is a major win for the food industry which is now globally in ascendancy in the policy tug-of-war over hard policies to reduce obesity.

Even with a Labor Government and a sympathetic minister, we end up with a set of soft options which promise to get harder over time but in reality are at high risk of staying soft.

The option to convert self regulation for junk marketing to children into statutory regulations is 2 elections away – that leaves a lot of time for industry lobbying and PR for the status quo.

The proposed voluntary front-of-pack labelling option has no planned track into regulations and the issue of taxing junk food is still recommended for investigation only.

The monitoring systems for keeping the industry on track and judging the ‘effectiveness’ of these voluntary schemes is not well specified.

The government is not responding to the report until next year and these monitoring systems may not be sorted out for another year or two – is that when the 4 year clock on industry action starts ticking?  The targets that have been set will never be met at that rate.

It was interesting how the physical activity options were always placed above the healthy eating options and that eating more (of the good foods of course) was always placed ahead of eating less (in fact, the eating less was not even present in earlier drafts).

In reality, to make a difference the order of importance needs to be reversed in both instances.  The hands of the ‘Hollow Men’ were clearly evident.

The Australian Communications and Media Authority report was just a joke.  After 2 years of consultations, deliberations and delays, they parroted the food industry’s flat earth statement that marketing of junk foods to children is not a contributor to obesity and a code that was essentially ‘business-as-usual’ apart from a ban on some cartoon characters for about an hour a day of children’s programming.

No wonder they were so ashamed of it they tried to release it under the shadow of the Taskforce report in the hope that it would not be noticed.

All the recommendations in the Taskforce Report are very positive and if the government enacts them all we will be well on the way to making major inroads into reducing obesity.

However, the same can be said of the 1997 NHMRC report ‘Acting on Australia’s Weight’ or the National Obesity Taskforce report ‘Healthy Weight 2008.’

The fact that neither of these were anywhere near implemented means we have to remain very guarded about the eventual impact of all the efforts of the Preventative Health Taskforce while we have a government so prone to being dictated to by big business.”

“On a recent trip to New Mexico, I was astounded to see large  billboards advertising cheap cigarettes at smoke shops on American Indian land. It turns out that American Indian and Alaska Native lands are sovereign nations and are not subject to state taxes or laws prohibiting the sale and promotion of tobacco products to minors.

As a result, Native American youth have access to cheap tobacco products at  a young age, and current smoking rates for Native Americans are over 30%. Tobacco is also considered a sacred gift and it is used during religious ceremonies and as traditional medicine although generally this is not the Nicotiana tabacum used in commercial tobacco.

While tobacco sales between Native Americans are tax free, tribal  smoke shops are supposed to collect taxes from other sales, but this is a huge loophole.  This tax-free loophole is also exploited with  internet sales.

Last month the first moves to close this loophole were made when a New  York Federal Court judge ordered a group of smoke shops on the Poospatuck reservation on Long Island to  stop selling tax-free cigarettes to the general public.

This week most of the nation’s largest tobacco companies filed a far-reaching lawsuit in  Kentucky to try to stop the landmark Family Smoking Prevention and  Tobacco Control Act, which President Obama signed into law in June, from curtailing their  marketing or forcing them to print large-scale graphic warning on  cigarette packages.  The lawsuit was not enjoined by Altria, which had  supported the bill, but which has said it has its own free-speech concerns with some parts of the new law.

The premise of the case is that tobacco is a legal product for adults  and that the First Amendment protects the industry’s right to communicate information about its products.  It was deliberately filed  in the US District Court of Kentucky which is seen as having been supportive to commercial speech issues.  It should be noted that, according to the Centers for Disease Control and Prevention, Kentucky leads the nation in smoking rates (28.6% in 2008) and has the highest rates of lung cancer among men and women.

Anti-tobacco lawyers have publicly stated that it was always clear  there would be just such a constitutional challenge and that the federal legislation was carefully worded to withstand such a legal test.  However lawyers on all sides agree that this issue is likely to end up before the Supreme Court.

• Lesley Russell is the Menzies Foundation Fellow at the Menzies Centre for Health Policy, University of Sydney / Australian National University, and a Research Associate at the US Studies Centre, University of Sydney. She is currently working in Washington DC.

Meanwhile, together with colleague Angela Beaton, Lesley Russell has just published this analysis of the 2009-10 state and territory health budgets at Australian Policy Online.

However, Professor Ian Olver, CEO of Cancer Council Australia, has a few suggestions for reforms that could be introduced without waiting for further reviews and reports and consultations.  He writes:

“In responding to the National Health and Hospitals Reform Commission A Healthier Future For All Australians: Final Report it would be trite to simply say that its impact will depend on  the detail of what the Government implements. Will we just see fiddling around the edges of health, or major reform, even as dramatic as a federal takeover of state hospitals?

Having waited for over half of the Government’s first term in office to see these recommendations, do we now have to wait for the establishment of a National Health Promotion and Prevention Agency to implement public health initiatives which are already backed by strong evidence?

In cancer prevention, for example, there is extensive evidence that the most effective way of decreasing the incidence of smoking with its positive health outcomes, is to increase the tax on tobacco. This measure could be implemented tomorrow.

Thirty lives could be saved each week by a fully implemented bowel screening program in Australia targeting everyone aged 50 and over. The evidence has shown this for more than 10 years, yet the current program provides only one-off screening to people turning 50, 55 and 65.

Clinicians in public hospitals already know about the inequities in drug availability and the wastage that occurs because of cost shifting, between the federal and state systems. High cost drugs, such as anti-cancer chemotherapy are being sourced by state hospitals from outside pharmacies. State hospitals provide minimal discharge medications, forcing patients to go immediately to their GPs for a prescription, ensuring the drugs are funded by the federal Pharmaceutical Benefits Scheme. In many cases it’s an unnecessary GP consultation, simply to save the hospital from funding the drugs. These measures shift the cost from the state to the Commonwealth, even though it’s the same taxpayer picking up the tab.

For high-cost drugs not listed on the PBS, patients are part of the lottery of either being wealthy enough to afford them, having some state hospital drug committees agree to fund them (usually on the advice of clinicians presenting research evidence), or relying on the sporadic generosity of health insurers or the repatriation system to fund drugs for individual clients.

There have been limited trials of federal funding of drugs in state hospitals, but federal funding of all drugs irrespective of public, private, inpatient or outpatient status would remove the inequities and the wastage in time and money of cost shifting.

Can we see such a commonsense measure implemented within the Government’s first term of office, without waiting for further agencies, reviews or consultations and more delay of such obvious health reforms?”

It’s time Mr Dutton, his staff, colleagues – and anyone else who happens to be poorly informed on this issue – became acquainted with an excellent initiative of the Centers for Disease Control in the US, the Community Guide to Preventive Services, which publishes recommendations based on rigorous systematic reviews of various public health interventions.

Even a quick perusal of the Guide’s website reveals that interventions to increase tobacco prices – including increasing tobacco taxes – have been proven to be an effective way of stopping adolescents and young adults from taking up the habit, reducing cigarette consumption, and increasing the number of smokers who quit.

The Guide says that such tax increases have also been shown to be more effective and have a greater public health impact when combined with other comprehensive tobacco control programs that reduce the prevalence of smoking through evidence-based policy tools. Increasing the price of cigarettes through tax increases can also diminish socioeconomic smoking disparities because low income groups are more responsive to price increases.

You can read more here.

The guide has also recently investigated the impact of increasing alcohol tax – another issue about which we hear a lot of poorly informed commentary.

It recommends increasing the unit price of alcohol by raising taxes, based on strong evidence of effectiveness for reducing excessive alcohol consumption and related harms, including such as alcohol-impaired driving, motor vehicle crashes and fatalities, and deaths from cirrhosis of the liver.

The effect of price on alcohol consumption is expressed as “price elasticity” or the expected percentage change in alcohol consumption when the price is increased by 1%.

Estimated price elasticities for different types of alcohol are:

* Beer consumption: -0.50, which means beer consumption would be expected to decrease 5% for every 10% increase in price.
* Wine consumption: -0.64, which means wine consumption would be expected to decrease 6.4% for every 10% increase in price.
* Spirits consumption: -0.79, which means spirits consumption would be expected to decrease 7.9% for every 10% increase in price.
* Total alcohol (ethanol) consumption: -0.77, which means total alcohol consumption would be expected to decrease 7.7% for every 10% increase in price.

Just because the Guide does not recommend a public health intervention does not mean that it doesn’t work – it may, for example, simply mean that the necessary and appropriate studies just haven’t been done. But when the Guide does recommend an intervention, it’s pretty safe to assume that there is reliable evidence to show it works and is worthwhile doing.

The question I’m left wondering is: when politicians and others make ill-informed statements, should the media just report them straight up and down? It doesn’t take too much journalistic effort or investigation to check out whether claims such as Dutton’s are based on evidence or hot air.

The beauty of cyberspace is that we are all only a few clicks away from an ever-increasing array of initiatives that aim to share the evidence about what works in both health and social policy.

As a child, he was regularly imprisoned in a car with heavy smokers, he said. “Both my parents smoked heavily wherever they were.”

He drew a few laughs when he threw back his arms, displaying his trim physique, and asked theatrically whether his childhood exposure had done him any harm.

While Abbott said he hoped parents wouldn’t smoke in cars with kids, it was probably far from the worst that they could do to their children, and he wouldn’t be inclined to legislate against it. “Being hard hearted to your kids and not encouraging them to do their best are far more important crimes,” he said.

Abbott’s comments must have rung a few bells for his opponent in the debate about the Nanny State, Professor Mike Daube, who has subsequently dug up the 2006 press release below from Christopher Pyne.

Daube’s comment: “His health might not have been affected by passive smoking, but his memory seemed to have been….”

THE HON CHRISTOPHER PYNE MP
Parliamentary Secretary to the
Minister for Health and Ageing

28 November 2006 CP81/06

Support for ban on smoking in cars with kids

Smoking in a confined space such as a car is particularly harmful and it is important to limit the exposure of children to this danger, the Parliamentary Secretary to the Minister for Health and Ageing, Christopher Pyne, said today.

Mr Pyne said he supported Tasmanian Senator Guy Barnett’s proposal to ban smoking in vehicles carrying children.

“Tobacco smoke is a combination of poisonous gases and breathable particles that are harmful to health, particularly that of children,” he said.

“In confined spaces, such as cars, babies and children can be exposed through passive smoking to these poisons and harmful particles.

“Smoking in a car is particularly harmful. It is, therefore, very important to limit the exposure of children to this danger.

“Children exposed to passive smoking are more likely to experience such serious illnesses as pneumonia, middle ear infections and asthma attacks.

“Every week, on average, someone under the age of 15 dies from a tobacco-related cause.

“Someone dies from the effects of passive smoking every second or third day – that is, five people every fortnight.”

“The effects of passive smoking on babies, in particular, must not be underestimated,” Mr Pyne said. “I commend Senator Barnett for making his stand on this and for calling on the states and territories to act.

“I shall raise these issues with state and territory ministers at the Ministerial Council on Drug Strategy on 15 December.”

Erstwhile Croakey correspondent Jennifer Doggett has written a piece for ABC-Online challenging the wisdom of  increasing tobacco tax, arguing that it would be regressive and harm the poor (it will “mean they cut back on other essentials, such as food, heating and housing costs.)

I suppose the corollary of this argument is that all caring people should support the lowering of tobacco tax to make it easier for those who smoke most (the poor) to keep on smoking and thus widen even further the smoking caused disease gap between rich and poor. What a perverse way of “helping” the poor while feeling good about social justice.

The poor, along with the young, are the most responsive to tobacco price rises. The heavy smoking Kerry Packer wouldn’t have cared less if he paid $13 a pack or $30, but budget conscious people do.

The responsiveness takes the form of quitting (the poor are quitting at broadly the same rate as the more well off, but from a much higher “ever smoking” prevalence) but also from reducing the amount smoked each day. Between 1980 and  2004, average daily consumption in Australia reduced from 20 (males) and 18 (females) cigarettes a  day to 14 – a 30% decline.

Along the way Jennifer trots out the myth that will not die that “seventy to 80 per cent of people with serious mental illnesses smoke and for people with schizophrenia the smoking rate is 90 per cent”.

A recent metanalysis of all studies of smoking & schizophrenia showed the average smoking prevalence was 62% (range 14-80%) with none topping 90%. (see Chapman S, Ragg M, McGeechan K. Citation bias in the reporting of the prevalence of smoking in people with schizophrenia. Aust NZ J Psychiatry 2009;43:277-82.)

While those with mental illness are under-studied, some evidence suggests that their cessation rates mirror those of the wider community. Yes, they smoke more, but their rate of decline (from a higher starting point) is not dissimilar to everyone else’s.

The only thing one needs to know about why tobacco tax is a the most effective way of bringing smoking down is to look at the tobacco industry’s reaction. Each year, you can set your watch by the predictability of their lobbying.

As Philip Morris put it with such candour as far back as 1983 in an internal memo “the most certain way to reduce consumption is through price”.