Smoking cessation in high-prevalence populations
Although the proportion of people aged 14 years of age and over smoking tobacco daily has continued to decline – from 16.6% in 2007, to 15.1% in 20101 the smoking rate is lower in more affluent, better – educated segments of the community, while the number of smokers in disadvantaged groups remains disproportionately high. The proportion of Australians who smoke is inversely related to the socioeconomic status of where they live – in 2010, 24.6% of people in areas with the lowest socioeconomic status smoked compared with 12.5% in areas with the highest socioeconomic status.1
In many countries, including Australia, social inequalities in tobacco use contribute to inequalities in health.52 There is a clear relationship between smoking and socioeconomic status, with disadvantaged groups in the population being more likely to start smoking and to remain long-term smokers. In particular, three sociodemographic variables are closely connected with the likelihood of smoking: education, family income and Index of Relative Socioeconomic Disadvantage.19,190 The most recent National Health Survey 2004–2005 indicates that smokers tend to report other lifestyle risk factors such as higher levels of alcohol consumption, lower daily fruit and vegetable intake and lower levels of exercise.25 There is extensive evidence that tobacco use contributes to poverty and inequality; encouraging smokers to quit has the potential to improve health and also to alleviate poverty.
The same guidelines for quitting smoking apply to all groups – every opportunity should be taken to offer all smokers advice and support to stop smoking.7 Counselling and behavioural interventions may be modified to be appropriate for the individual smoker. Quitlines and other service providers have been trained for clients from many high-prevalence groups, including Aboriginal and Torres Strait Islander people. All nicotine-dependent smokers should be offered pharmacotherapy, unless contraindicated.
Aboriginal and Torres Strait Islander people
Approximately 41% of the Aboriginal and Torres Strait Islander population are current daily smokers, a prevalence rate more than double that of the non-Indigenous Australian population.1,2
The fact that there has been a fall in smoking rates shows that tobacco control efforts can be effective in Aboriginal and Torres Strait Islander communities. If the smoking rate among Indigenous Australians can be further reduced to that of the non-Indigenous population, the overall Indigenous burden of disease should fall by around 6.5%, and provide improved life outcomes for around 420 Aboriginal and Torres Strait Islander people each year.179
Compared with other Australians, Aboriginal and Torres Strait Islander people experience socioeconomic disadvantage across a range of indicators including education, employment, income and housing. Because of the strong association between low socioeconomic status, poor health and increased exposure to health risk factors, smoking is a major contributor to the large life expectancy gap (12 years for men and 10 years for women) between Indigenous and non-Indigenous Australians. Aboriginal and Torres Strait Islander people experience higher mortality from a number of smoking-related diseases (including cardiovascular diseases, lung cancer and other cancers and chronic respiratory disease) compared to the general Australian population.180
Though various smoking cessation methods have been shown to be effective across different racial and ethnic groups in other countries,99 there has been a lack of research and evaluation of tobacco interventions in the Indigenous Australian population. Smoking cessation methods identified as being effective, such as brief advice and pharmacotherapy, should be provided for all smokers, as they are likely to be effective, especially if delivered in culturally sensitive ways.
Effective smoking cessation methods should be modified or tailored to meet the needs of Aboriginal and Torres Strait Islander people in consultation with the community. This approach can involve working in collaboration with Aboriginal health workers. Appropriate cessation services for Aboriginal and Torres Strait Islander people can be found at the Centre for Excellence in Indigenous Tobacco Control at www.ceitc.org.au/quitting_resources
Specific barriers to smoking cessation treatment for Aboriginal and Torres Strait Islander people, such as the social context that normalises smoking, are being addressed by healthcare workers in many Aboriginal communities. There is also evidence that this population uses medicines at a lower rate than other Australians – despite initiatives in place to improve access to treatment. Other factors – such as a high level of stress in Indigenous communities, lack of availability and access to culturally appropriate health services, language barriers and high rates of smoking among Aboriginal health workers – are a significant barrier to the success of smoking cessation strategies for Indigenous communities.181
People who identify as Aboriginal or Torres Strait Islander qualify for the PBS Authority listing for NRT, which provides up to two courses per year of nicotine patches, each of a maximum of 12 weeks. Under this listing, participation in a support and counselling program is recommended but not mandatory.
Closing the Gap PBS co-payment measure
The Closing the Gap (CTG) measure is part of the Australian Government’s Indigenous Chronic Disease Package, established to improve access to medicines by reducing the cost of accessing PBS medicines for eligible Aboriginal and Torres Strait Islander people who are living with or are at risk of chronic disease.
Under this measure, eligible patients must be registered at a rural or urban Indigenous health service, or a general practice that participates in the Indigenous Health Incentive (IHI) under the Practice Incentives Program (PIP) in order to receive a CTG-annotated PBS prescription.
Depending on the Indigenous patient’s concessional status, when a CTG-annotated prescription is dispensed at a pharmacy, the patient pays a lower, or nil, copayment for all PBS medicines. A concessional patient’s copayment reduces to nil and a general patient’s copayment reduces to that of a concessional patient. Some suppliers of PBS medicines impose a brand premium on some brands of medicine, which the patient must pay. Brands that carry a manufacturer’s surcharge are indicated by a ‘B’ on the PBS Schedule.
For further information email PBS-Indigenous@health.gov.au or visit www.medicareaustralia.gov.au/provider/pbs/prescriber/closing-the-gap.jsp
- Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW, 2011. Available at www.aihw.gov.au/publicationdetail/?id=32212254712&libID=32212254712&tab=2 [accessed 12 August 2011].
- Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander people. Cat. no. IHW 40. Canberra: AIHW, 2011. Available at www.aihw.gov.au/publication-detail/?id=10737418268 [accessed 19 August 2011].
- Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking cessation guidelines for Australian general practice: practice handbook. Canberra: Australian Government Department of Health and Ageing, 2004.
- Australian Institute of Health and Welfare. Australia’s health 2010. Cat. no. AUS 122. Canberra: AIHW, 2010.
- Australian Bureau of Statistics. 4831.0.55.001. Tobacco smoking in Australia: a snapshot 2004–05. September 2006. Available at www.abs.gov.au/ausstats/abs@.nsf/ mf/4831.0.55.001 [accessed 28 March 2011].
- National Institute for Health and Clinical Excellence. NICE public health intervention guidance – brief interventions and referral for smoking cessation in primary care and other settings. London: NICE, March 2006. Report no. N1014.
- Aubin H-J, Bobak A, Britton JR, et al. Varenicline versus transdermal nicotine patch for smoking cessation results from a randomised open-label trial. Thorax 2008;63:717–24.
- Australian Government. Department of Health and Ageing. National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes: Implementation Plan. Canberra: Commonwealth of Australia, 2009.
- Australian Bureau of Statistics and Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. ABS cat. no. 4704.0. AIHW cat. no. IHW14. Canberra: AIHW, 2005.
- Mark A, McLeod I, Booker J, Ardler C. Aboriginal health worker smoking: a barrier to lower community smoking rates? Aboriginal Islander Health Worker J 2005;29:22–6.
- Mendelsohn C. Teenage smoking. How the GP can help. Medicine Today 2010;11:30–7.