Tobacco control and closing the gap

Tom Calma,
Aboriginal and Torres Strait Islander Social Justice Commissioner

Oceania Tobacco Control 09 Conference

Opening Keynote speech:
Tobacco control and closing the gap

7 October 2009


OPENING SLIDE

Tobacco control and closing the gap

Tom Calma, Aboriginal and Torres Strait Islander
Social Justice Commissioner and
Chair of the Close the Gap
Steering Committee for Indigenous Health Equality

Oceania Tobacco Control 09 Conference
7 October 2009

 

(a) Introduction

Thank you Dr Ian Olver for that warm introduction and Dr Alita Fejo for your welcome to country.

I begin by acknowledging the Larrakia people, the traditional owners of the land where we meet today, and to pay my respects to their elders and ancestors. Our Kungarakan lands share a common border with the Larrakia so I am doubly pleased to acknowledge good neighbours – and can I also say that it’s good to be back home in Darwin, and to catch up with friends and family here today.

I also thank the Cancer Council, and Helen Smith of the Cancer Council Northern Territory for hosting this event and inviting me to speak with you today.

I would also like to thank Stephen Hall for his assistance with this speech.

And I acknowledge my fellow speakers and Minister Kon Vatsikalis and the many distinguished people in the audience, particularly my Indigenous brothers and sisters from Australia and overseas present here today, and also the many non-Indigenous professionals and supporters here. Your support for Indigenous health and health equality is vital and acknowledged.

As Ian mentioned I am a White Ribbon Ambassador so let me spend a minute to talk about the White Ribbon Campaign. The campaign is about men who encourage other men to publicly champion non-violent relationships in our community. We campaign to end violence against women all year but especially on White Ribbon Day, which falls on the 25th of November each year. I encourage other men to become involved. Have a look at the White Ribbon Day website and learn about ways that we men can lend our support, including signing the Oath, to speak out against family violence.  

For those of you who don’t know me or what the role of Aboriginal and Torres Strait Islander Social Justice Commissioner involves, among my responsibilities, I monitor the human rights of Indigenous Australians and I report annually - in the Social Justice Reports - to the Australian Parliament in that regard.

I also monitor the impact of the Native Title Act and developments around native title on us in a second report - the Native Title Report that is also tabled to the parliament.

And for those keen to read these, I have copies available on CD-ROM here for you to take.

Slide 2

Publication covers

Main Campaign elements

  • Partnership between Indigenous peoples/ Aust govts.
  • National plan for health equality by 2030
  • Ambitious targets and benchmarks

I am also the Chair of the Close the Gap Steering Committee, the committee behind the national Close the Gap Campaign for Indigenous Health Equality, and it is in both capacities that I will be speaking with you today.

And for those of you who may not know about the Campaign, since 2006, Australia’s peak Indigenous and non-Indigenous health bodies, NGOs and human rights organisations have worked together on the Close the Gap Campaign for Indigenous Health Equality to close the yawning life expectancy gap between Indigenous and non-Indigenous Australians within a generation.

The key elements of our approach, based on the right to health of Indigenous peoples in Australia, are the development of:

  • A partnership for Indigenous health equality between government and Indigenous peoples and their representatives.
  • A comprehensive national plan of action that is properly resourced and that has the goal of achieving Indigenous health equality by 2030.
  • Within the national plan, a targeted approach to achieving Indigenous health equality, focusing on a wide range of health conditions and health determinants, including smoking.
  • Support for Aboriginal Community Controlled Health Services, and
  • An address to the social and cultural health determinants of our poorer health.

I have some Campaign literature here for you to take if you are interested in finding our more about it.

I’m pleased to report that the Campaign has been very successful with Australian governments committing to this approach in March 2008 by signing the Close the Gap Statement of Intent with substantial investments of upwards of $5bn going to Indigenous health and related areas (all branded ‘closing the gap’) largely as a result of the Campaign.

And thank you for the opportunity to talk about reducing smoking among our peoples and the enormous contribution this can make to ongoing efforts to close the Indigenous and non-Indigenous life expectation gap.

(b) Body of speech

Let me speak plainly about this subject.

Smoking causes havoc in our communities. It is a scourge. When you look at the numbers involved, it is far more insidious than many of the other problems that get the headlines in relation to Indigenous Australia. Yes, family violence and so on must be addressed - indeed, it is vital that they are addressed - but none of these kill up to one in five Indigenous people, directly and indirectly, as smoking does, or have otherwise addicted half our population to an expensive and insidious habit.

Slide 3

Health impacts of smoking

  • Indigenous people more than 1.5 times more likely to die of lung cancer than non-Indigenous Australians. Higher rates recorded in some communities.
  • Overall, death rates from respiratory diseases, approx 4 times higher than non-Indigenous Australians.
  • Heart disease – approx 3 times higher than non-Indigenous Australians.

 

And while I assume it to be unnecessary to recant the awful statistics relating to Indigenous smoking related deaths and disease compared to the non Indigenous population to such an expert audience, I have included these on the slides behind me for anyone who may not be aware of there.

And this is just a sample of the health impacts of tobacco use taken from the Australian Institute of Health and Welfare’s excellent 2008 edition of The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples.

It cannot be said loudly enough - smoking is the single most devastating cause of death and disease among our peoples. The price of smoking is literally thousands of pre-maturely dead Aboriginal and Torres Strait Islander people: cultures and communities without elders; dying languages, lost traditions; children without parents; absent grandparents, uncles and aunties, and the great burden of grief and suffering that comes with it.

Tobacco is in fact the only legal and otherwise easily available drug that rapidly addicts and over time kills its consumers even when it is used entirely as intended.

The morality of tobacco sales are in my mind questionable. But without wanting to dwell on this, in relation to sales I want to note that we, Indigenous peoples, need to be particularly concerned about any vestiges of tobacco promotion in our communities given that studies show that Aboriginal and Torres Strait Islander children and adolescents take up smoking earlier than their non-Indigenous counterparts. Addiction to nicotine is therefore more likely to be established at an earlier age in our kids than for other Australians.

As a result, our people die younger from tobacco-related illness than do non-Indigenous people.

But there is some good news in this market-driven context. That is that smoking related death and disease is entirely, 100% preventable, to the degree you dissuade people from buying and using tobacco products. Choice remains the key, although the issue of ‘consumer choice’ in this context is of course clouded by the choice-denying impact of addiction.

It has been a triumph of the public and preventative health movement and a testament to the value of health promotion and education that smoking rates in the general population have massively tailed off in past decades.

Slide 4

Smoking rates – rapid declines needed in Indigenous population

  • Indigenous people more than 1.5 times more likely to die of lung cancer than non-Indigenous Australians. Higher rates recorded in some communities.
  • Overall, death rates from respiratory diseases, approx 4 times higher than non-Indigenous Australians.
  • Heart disease – approx 3 times higher than non-Indigenous Australians.

 

It is worth reflecting on the fact that this drop is from rates that were apparently even higher than that of Indigenous Australians today. It has been estimated that approximately 75% of men in the general population smoked in 1945. Under 18% of men and women in the general population smoke today. And I note that in the recently released proposal for a National Preventative Health Strategy there are moves afoot to reduce that to 10% by 2020.

Of course, what I want to see is the same kind of rapid reduction in smoking rates among our peoples that have been seen among non-Indigenous Australians but within much shorter time frames. Smoking rates of around 50% (and up to 80% in remote communities and prisons) have been reported for decades now among us and this, tragically, remains the picture today. Let’s look forward to the day that this rate is zero or statistically insignificant.

So how did we get ‘here’?

Slide 5

How did we get here?

  • Smoking tobacco is a colonial legacy with no cultural foundation
  • Failure of reach of health promotion and education
  • Symptomatic of deeper social and cultural problems
  • Failure of Indigenous community to face up to and own the extent of the problem – failure of leadership

 

I want to make several points in relation to understanding how Indigenous smoking rates got to be as high as they are, but first I want to address a myth that has sometimes clouded the debate around Indigenous smoking, particularly among our own people.

It is true that some of our peoples traditionally used native tobaccos. Aboriginal people have chewed the dry leaves of pituri and native tobacco prior to contact with non-Aboriginal people. Some Aboriginal people continue to use pituri and native tobaccos.

However, lets not get confused here - packets of Marlboro ‘reds’ and bulk-packs of 50 Holidays (and so on) are not part of our culture and have no cultural support whatsoever!

In fact tobacco, if anything, is a sign of our historical oppression and social control.

Let no-one forget that many Aboriginal and Torres Strait Islander workers were paid with tobacco rations, instead of money, until the 1960s(!), laying the foundation for generations of Indigenous tobacco-addicts and a norm of smoking in many of our communities that persists today.

So, to any one of my brothers or sisters who tries to justify smoking or chewing non-traditional tobacco as part of ‘who we are’ as peoples, I ask them to think again. Such confusion is literally deadly: the addiction and diseases brought on by abuse of non-traditional tobacco is a post contact legacy.

In fact, as I am sure many of us here are aware - It’s clear that poverty, oppression and smoking are linked.

And indeed, it is a common observation that underneath the high rate of smoking in our communities lay factors such as dispossession, cultural and community breakdown, family breakdown, institutionalization, poverty, and generally lower exposure to quality education. And all these are valid to point out.

Having highlighted that, I am also aware that to get too ‘generalized’ about the causes of smoking can blind us to the value and need for targeted anti-smoking interventions in our communities. It can also lead to the idea that tackling Indigenous smoking rates belongs in the ‘too hard basket’; being perceived as requiring an address ‘to everything’, and of course resulting in nothing being done!

In fact, interventions in terms of preventative and primary health care are absolutely necessary.

Slide 6

Challenging norms around smoking

  • Awareness raising – education vital
  • Norms changing – role of Indigenous leadership , including community leaders, health workers and parents is vital

 

Health education and non-smoking messages

Health education as to the risks of smoking must be in the mix if real choices for not smoking are to be made by Indigenous people.

Some studies have shown very low levels of awareness of the medical problems caused by smoking. In particular, smoking is not widely perceived to be a cause of most deaths among us.
Culturally tailored messages (sometimes using art, song, dance and storytelling) have also been used to convey messages about tobacco use.

School education programs and mass media campaigns can reduce uptake of tobacco use among young people and are absolutely vital government tools in addressing smoking rates among our peoples.

This includes the use of tailored no-smoking health promotion materials, including self-help materials, to help smokers to quit.

Norms and leadership

And the value of this education and anti-smoking messaging is that ultimately this fosters a non-smoking norm of behavior in communities as well as encouraging individual no-smoking.

Tragically perhaps, sharing tobacco still in 2009 plays a large part in the social life of many our people. Using tobacco reinforces family relationships and friendships. While we want our communities and relationships to remain strong, it is important that tobacco smoking is replaced as social currency with more health positive activities.
That these norms can exist today point to a failure of governments to ensure the anti-smoking message and no-smoking norm, so prevalent now among non-Indigenous Australia, have reached our communities.

However, pointing the finger at the government does not do full justice to this issue. It’s a tough call to make and hard to face up to, but there has also been a failure of leadership within the Indigenous community in relation to the no-smoking message.

By leadership, I don’t just mean people like myself, I mean community leaders setting the example for the community and teachers and health workers and even parents setting the example for their kids. And while I have taken aim at tobacco companies who have promoted their products to our kids, let’s be clear that if we, Indigenous adults, smoke around our kids, we are doing the job for these companies, and in a far more effective way than they could possibly ever dream of.

In 2004–05, an estimated 119,000 Aboriginal and Torres Strait Islander children lived with a regular smoker. This represents two-thirds (66%) of all Indigenous children aged 0–14 years. In comparison, around one-third (35%) of non-Indigenous children aged 0–14 years lived with a regular smoker. Regular smokers may or may not smoke at home indoors. Some 28% of Aboriginal and Torres Strait Islander children were living in households with a regular smoker who smoked at home indoors, three times the comparable rate for non-Indigenous children (9%).

What this means is that impressionable Aboriginal and Torres Strait Islander children are three times as likely to live in households with a regular smoker, or a smoker who smoked at home indoors, as non- Indigenous children in major cities and regional areas respectively.

And of course, in relation to these kids, lets not forget that not only are they taking in smoking as a norm by example, they are literally taking in the smoke – passive smoking in other words. And this would only exacerbate the significantly greater existing burden of ill-health suffered by our kids, including a growing number of asthmatics, when compared to non-Indigenous kids in this country.
So leadership at all levels is absolutely vital here. Government has a role to play, but so too we Indigenous adults - be we parents, teachers, health workers or leaders - we need to be taking this seriously, overcoming our addictions if we have them, and setting the example for our kids and our communities. A major challenge for all of us is to uproot any norm that says smoking is OK and acceptable in Indigenous Australia.

And in passing, can I mention the excellent work of The Centre for Excellence in Indigenous Tobacco Control and Vicki Briggs in offering Indigenous leadership in this area, and bringing together researchers and policy makers to look at solutions to this issue.

As Ian mentioned; one solution that might be appropriate in Sydney does not fit all situations so the work of CEITC is so important to ensure that we have appropriate solution for specific situations. Further, because we are the fasted growing population group in Australia and because over 50% of the Aboriginal and Torres Strait Islander population is under 25 years of age, it is also important to engage with our youth to get their views on the appropriate solutions and addresses for their demographic.

Legislative responses

Slide 7

Role of government

  • Health promotion and education
  • Limiting advertising and tobacco promotion
  • Restricting tobacco usage in pubs and clubs
  • Supporting communities to limit sales (along the lines of alcohol restrictions)

 

Another role government can play is in supporting education about the risks of smoking and the development and maintenance of no-smoking norms through legislation and regulation.

And as I have touched on already, control of advertising and promotion of tobacco products is vital. Some of our communities may be able to further limit advertising and promotion locally - for example by putting all tobacco products under the counter in community stores - to enhance this overall no promotion approach.

Finally, restricting the availability of tobacco through local by-laws has been implemented successfully in Indigenous communities overseas. By-laws relating to tobacco have not as yet been tried in our Aboriginal and Torres Strait Islander communities, although comparable controls have been adopted by some communities for alcohol. This maybe an option more and more communities are willing to explore as the full negative impacts of smoking become more clearly understood.

Primary health care and other health settings

Slide 8

Health services

  • No smoking messages across the board (PHC, hospital)
  • Focus on mothers
  • Staff -- Leadership by example
  • NRT – Medicare subsidy
  • Quit lines, support groups

 

Another tool in the battle against smoking comes from the delivery of the no-smoking message and other support through primary health care and hospital settings, and, in the case of Indigenous Australians, particularly through community controlled primary health care services.

There is a sound evidence base that the anti-smoking message coming from health professionals - doctors, nurse and others - in both primary and hospital settings can help smokers quit.

In particular, interventions to assist pregnant women to quit as a part of maternal health programs are successful in decreasing tobacco use and increasing the birth-weight of babies.

Training Aboriginal Health Workers, nurses and doctors to promote no-smoking is a vital part of any strategy to deliver interventions through primary health care (including through the community controlled services) and hospital care settings. And as I have highlighted, it is vital that health workers lead by example too -- in health settings and in the broader community.

It is also vital that people are able to access a range of supports for stopping smoking through primary health care and other health care settings.

There is good evidence that ensuring access to Nicotine Replacement Therapy (NRT) will increase the quit rate in Aboriginal and Torres Strait Islander people. And I welcome the Government’s PBS subsidizing of the cost of NRT for our people announced in December 2008. And there is a place for tailored Quit courses or support groups in this context also.

To conclude this section of my speech, while the causes of Indigenous smoking are complex, at very least, an Indigenous ‘catch up’ by encouraging our people to quit through education, and challenging pro-smoking norms, on the same scale we have witnessed among non-Indigenous Australians must be attempted and should be a major focus of our health professionals, community leaders’ and Australian government’s efforts to close the life expectation and health equality gap. And as I hope I have illustrated here, there are many practical ways to go about doing this.

Current governments’ efforts

So how then do the efforts of Australian governments measure up against this identified need and in the light of all the tools available to them?

First, I welcome the real increase in awareness around this issue that is coming through government in recent years, but the challenge is to see that awareness bedded down and translated into real action on the scale necessary.

In part, this has been through the efforts of the Close the Gap Campaign. As part of its efforts the Campaign proposed several targets that directly addressed smoking, notably reducing Indigenous people’s use of tobacco to the general populations’ rate by 2020 - a target that was extremely ambitious but one that we felt was essential if Indigenous health equality was to be achieved within a generation, as the governments of Australia had committed to at the December 2007 COAG meeting.

So from the start, tobacco use was in our sights as requiring a massive and comprehensive address.
And the Government, to its credit, has responded with a number of initiatives including the $14m no-smoking package announced in March 2008 and the $1.6bn COAG National Partnership on Closing the Gap in Indigenous Health Outcomes, which is currently being implemented. The National Partnership as it stands includes commitments to:

  • Social marketing campaigns to reduce smoking-related harms among Aboriginal and Torres Strait Islander peoples.
  • Indigenous specific smoking cessation and support services.
  • Continued regulatory efforts to encourage reduction/ cessation in smoking, and
  • Strategies to improve delivery of smoking cessation services, including nicotine replacement therapy.

And these directions have also been echoed in the recently handed down proposal for a national Preventative Health Strategy.

Of course, the 2004 Australian National Tobacco Strategy continues also as a part of this mix and makes some valuable points that are otherwise common-sense from a policy perspective and should inform all the above government efforts, particularly in relation to the cultural tailoring of the no-smoking message for our communities and the need for a partnership approach with, for example, the community controlled sector.

So all this is welcome, but how could it be improved?

Slide 9

Calls

  • National strategy aimed at rapid reductions in the rates of smoking among Indigenous Australians, to support the broader goal of Indigenous life expectation and health status equality by 2030.
  • A commitment from Indigenous leaders and adults to set the example for our kids and to ensure a no-smoking norm for Indigenous Australia

 

As I have highlighted, one of the main elements of the approach of the Close the Gap Campaign is for a national plan for Indigenous health equality within a generation (by 2030) to be developed. An absolutely vital part of this would be a comprehensive, longer-term, national Aboriginal and Torres Strait Islander tobacco control strategy that brings together the various programs and research and, in partnership with Indigenous peoples and their representatives, aims to drastically reduce smoking rates as soon as possible.

And so I finish my speech with a call for a national effort to drastically reduce smoking rates in our communities in such a manner and with the overall ambition of achieving health equality for Indigenous Australians within a generation, by 2030.

I believe that the unique alignment of forces makes this possible now, or more possible now, than any other time I have known. And without this foundation element, no other plan for broader health equality within a generation is likely to be feasible.
We must take a stand now for an Indigenous Australia that does not smoke, as we must for an Australia that does not smoke. We need a national plan and we need it now - Indigenous Australia cannot afford to wait.

Such a plan requires significant investment on the part of governments as well as a real commitment to partnership with Indigenous peoples and their representatives at the national, regional, community and even family levels.

 

And finally, it requires that Indigenous peoples ourselves start to own this issue as a major problem within our communities. That anyone in any position of leadership - even if this is just in terms of being a parent - take this on as their business. And ensure that a no-smoking norm emerges within Indigenous Australia as soon as possible and that our young people do not share the insidious colonial legacy of tobacco addiction that afflicts us today.

Working together, and with Australian governments, I am convinced that we can rise to this challenge. Working together I am convinced that we can look forward to a smoking - free future for Indigenous Australia and far sooner than you might otherwise think possible.

And on that note, I wish you well for your conference, and I look forward to the contribution it can make to Indigenous health, and the health of all Australians.

Thank you.

Address: 
  --
Australia