The smoke must clear before we close the gap

Opinion Article

2011 February, 26

Tobacco became the drug of choice for Aboriginal people from the instant of European colonisation. Famous anthropologist Bill Stanner wrote about its great allure to the remote  tribes of northwest Australia in the 19th and early 20th centuries.  

Wik people from the gulf coast walked hundreds of kilometres to the white outpost of Coen  to seek the new drug in the old days.  

I remember as a child watching my grandfather cutting what was called plug tobacco to put  into his old pipe. The slab of compressed tobacco leaves and tar was said to have been the detritus discarded from the tobacco factory floor: the little metal stamp read “For Aboriginal  Use Only”.  

Smoking is the single biggest contributing factor to the life expectancy gap between  indigenous and non-indigenous Australians.  

Fifty-one per cent of indigenous people smoke, compared with a 17 per cent smoking rate across the general Australian population. Indigenous smoking rates have not decreased during the past 15 years. If the level of smoking among indigenous people were brought down to general Australian levels, health researchers say that 20 per cent of the life expectancy gap would close.

Despite the great gains made in anti-tobacco campaigns in Australia in recent decades, this  has not been reflected in indigenous communities. 

It is three years since I turned my mind to the question of what I would do to tackle the  appalling tobacco problem in communities such as my home town in Cape York Peninsula.  

I asked a group of experts from medical research organisations and health service  professionals to share their knowledge about the phenomenon of smoking, hoping to learn  what strategies are effective in tackling smoking in the wider community and in indigenous  communities specifically.  

Like so many behavioural problems, smoking does not admit to easy solutions. To be  effective some responses require a preparedness to be paternalistic.  

The unwillingness of most of those who work as public health professionals to contemplate measures that intervene in the choices made by adults – even where these choices adversely affect non-smokers around these adults, including children – means most of the anti-smoking strategies that I have learned about are not convincing.  

In fact, most of them are useless, and if we continue to do these things we will not make progress in the fight against tobacco in our communities.

The thing about researchers is that they often know a great deal about all of the details of phenomena such as smoking, but they are not very good at compelling policy responses. Their insight, information and evidence are important, but more often than not I am not  persuaded by their ideas about what should be done.  

So what do I propose we do to tackle smoking in the remote indigenous communities that I  am concerned about in Cape York? I will outline the strategy I proposed in 2008.

The strategy is premised on the idea that because we are dealing with discrete communities with defined populations, it should be possible to aim interventions at all members of a community.

With captive populations, individual case management and comprehensive targeting of community members are theoretically possible.  

I came up with a seven-pronged approach.  

First, we need a comprehensive strategy to prevent the taking up of smoking by people under 18. Researchers told me that if individuals can avoid experimenting and becoming addicted to smoking in the danger period between primary school and their teenage years, then the chances of taking up smoking later in their adulthood are very much reduced.  

Second, we need a comprehensive strategy to prevent the taking up of smoking or encourage the quitting of smoking among mothers-to-be, and for the abstention and quitting of smoking among pregnant women.  

Third, we need a comprehensive strategy to stop smokers from affecting the health of  children. This includes parents and relatives. It means we have to change what happens in public places, in private homes and in motor vehicles. This, too, is not easy, but I cannot see  how subjecting children to adult smoking does not constitute neglectful or abusive behaviour by the adults.

Fourth, we need a comprehensive strategy to stop smokers from affecting other people.  

This is a well-established norm in the wider Australian community. Spatial restrictions on smoking are now legally mandated. These restrictions need to be embedded in the life of indigenous communities.  

Our three remaining proposals concern existing smokers. There are two things we want from them. The first thing we want is their support for the first four strategies. Even though they  may be struggling with their own addiction to tobacco, they can nevertheless support efforts  aimed at ensuring other community members, particularly the younger generations, maintain  good health. The second thing we want is for them to quit smoking for their own sake.  

The smokers can be categorised into three groups.  

The first is the red light group who have not thought about quitting. We need to support them  to start thinking about quitting.  

The second is the amber light group who have been thinking about quitting, but have not  made a serious attempt. We need to support them to take the plunge.  

The third is the green light group who have been trying to quit. Researchers tell us that it  takes an average of five attempts for smokers to succeed. We need to support this group to  quit.  

My main idea for prevention of smoking among young people is the concept of a program of financial incentives for teenagers. That is, I would like to run a proper randomised trial of the effect of financial incentives for young people, say aged between 12 and 21, to abstain from smoking. 

I tried to galvanise support for a trial of these ideas in 2008. I was not successful.  

Three years have passed and there is still nothing happening in this crucial area. We can talk about closing the gap all we like, but only when the smoke clears will a healthier indigenous people emerge.

The smoke must clear before we close the gap