Making tobacco a service delivery priority for disadvantaged groups
"Making tobacco a service delivery priority for disadvantaged groups" a future directions paper submitted by by Alcohol Tobacco and Other Drug Association ACT
Future directions paper - August 2011
1. PurposeThe purpose of this paper is:
- To highlight some current issues and challenges related to tobacco and disadvantage;
- To propose some strategies to further support putting tobacco on the agenda, particularly at the service delivery level; and,
- To share this information with key stakeholders as a motivator for action, including the ACT Alcohol, Tobacco and Other Drug Strategy Evaluation Groupʼs newly established Tobacco Working Group.
2. Tobacco and disadvantageExposure to tobacco smoke has been linked to a multitude of adverse health consequences. Smoking has been identified as the leading preventable cause of death and disease in Australia. iSmoking is not only a major contributor to chronic disease1 but also places great pressure on our health system and leads to reduced productivity and participation in our workforce and community.ii
Despite a drop in the amount of daily smoking rates, tobacco accounts for 65% of the overall burden of disease and injury2 nationally.iiiWhilst the national prevalence of daily smoking reported by respondents aged 14 years and over is 16.6%, the ACT rate is 14.7%, iv there remain sub-groups of the population who have higher rates of smoking and require a particular focus.v
Whole of population initiatives have had significant effects in the broader community. Yet sub-groups have proven resistant to these initiatives, still have defiantly higher rates of smoking and are disproportionately affected by the damages associated with smoking. Further reductions in the prevalence of daily tobacco smoking will be difficult without specific attention and interventions directed at high prevalence subgroups in the Australian community. vi As such, these population groups require targeted research, interventions, and support.
Tobacco smoking amongst disadvantaged groupsWhile smoking rates have declined significantly in Australia in the last 30 years, they remain higher amongst the most disadvantaged and vulnerable groups within our society.viiAlthough smoking causes harms across all population groups, particular sections of the community are disproportionately affected. Common features that span the sub-groups disproportionately affected by smoking are less education, unemployment, social isolation, interpersonal conflicts and being poorer. viiiThese conditions are key elements of the social determinants of health and wellbeing, attributed as responsible for avoidable and unfair inequalities in health and wellbeing.
The link between social disadvantage and smoking is complex; however, smoking contributes to and reinforces these social risk factors, compounding the likelihood of adverse health outcomes. People living with a mental illness, people experiencing alcohol and other drug issues, and disadvantaged young people are three groups that have been identified as priority population groups for decreasing the harms associated with smoking, and are the target groups for the Workplace Tobacco Management Project.
Rates of smoking amongst clients of alcohol and other drug support services are alarmingly high. Some sources estimate that 95% of people in alcohol and other drug treatment are current smokers.ix According to a 2007 survey of illicit drug users (IDRS) some 98% of ACT respondents identified as being current smokers.x In comparison, according to the 2007 National Drug Strategy Household Survey, 16.6% of Australians aged 14 years or older were current smokers. xiThis highlights the disparity between people with alcohol and other drug issues and the general population regarding rates of smoking.
Similarly, although reports vary, smoking rates amongst people living with a mental illness are high when compared with the general population. A recent University of Melbournexii study of psychiatric support service clients found that 62% were current smokers. Of those 59% expressed a desire to quit, and 74% to reduce tobacco smoking. Other sources suggest the smoking rate amongst this population is approximately 75%.Furthermore, evidence suggests that the poorer physical health of people living with mental illness3 is greatly related to smoking.xiii
Young people (aged 12 - 25 years) are an obvious target for early intervention and prevention of tobacco consumption, especially given the mean age of smoking initiation in 2007 was 15.8 years of age (15.1 for males and 16.1 for females). xivFurthermore, the younger a person begins smoking the more likely they are to become a regular smoker and less likely to quit. xvHowever, akin to the broader community, disadvantaged young people have higher rates of smoking than other young people. As with other age groups, smoking rates are higher amongst young people who are living with a mental illness and are using alcohol and other drugs.
3. Policy contextThe Commonwealth and State and Territory Governments have recognised the impact that preventable health conditions have on the Australian community and are investing in establishing a range of health promotion programs and strategies
targeting settings such as communities, schools and workplaces. For example, the ACT 2009-10 Budget xvi committed funding over three years to support the Healthy Future-Preventative Health Program. This program is aimed at promoting healthy lifestyles and reducing risk factors for chronic disease, and includes initiatives for the development and implementation of ACT workplace health promotion programs.
Smoking cessation is also identified as a priority under the National Partnership Agreement on Preventive Health.xvii Under the Agreement, States and Territories have agreed to fund local level activities in support of national anti-tobacco campaigns, and to implement healthy lifestyle programs in workplaces targeting, amongst other things, smoking cessation.
Additionally, chronic disease has seen a renewed policy and programmatic focus from all Governments, particularly flowing from Health and Hospitals Reform initiatives and Chronic Disease Packages (including those for Aboriginal and Torres Strait Islander communities). Within many of these tobacco is considered a key target.
Across these areas, focus on people in our community that have proved resistant to actions to date is minimal; which may require implementation of strategies that specifically address smoking as it relates to disadvantage.
5. Key issues for considerationDespite the evidence, the resourcing and the expressed policy commitment highlighted throughout this document, it appears that tobacco management, support and interventions are not reaching those who need it most – particularly
disadvantaged groups. Below are six areas which have been identified as strategic areas for further development to effectively reduce tobacco related harms with disadvantaged groups in the ACT.
5.1 GovernanceIt is acknowledged that reducing tobacco related harms is a priority health issue requiring a whole-of-government and whole-of-community response. Despite this, the governance and management of tobacco appears to be divided across the ACT
Government and sectors, and delivered in a somewhat ʻad-hocʼ fashion. This has meant there has not been clear responsibility, accountability or mechanism to progress tobacco management strategies.
The establishment of the new Tobacco Working Group (June 2011), as an arm of the ACT Alcohol, Tobacco and Other Drug Strategy Evaluation Group, provides an essential opportunity and mechanism to specifically progress tobacco as a priority action under the ACT Alcohol, Tobacco and Other Drug Strategy 2010-2014 and within the ACT.
5.2 Leadership and coordinationDespite the significant media and policy leadership regarding tobacco there appears to be a lack of leadership in the government and non-government sectors in putting tobacco on the agenda, and for it to be embedded within service delivery – particularly given the linkages with disadvantage. This extends to coordination of the service delivery response to tobacco resulting in short-term ʻbandaidʼ funded programs, unclear overarching goals, and potential lack of sustainable outcomes.
Future directionsSector leadership is required including within allied sectors, such as housing and homelessness. Strategies will need to be developed to promote and engage stakeholders to engage in, demonstrate and maintain this leadership. These could
include various incentives such as funding, promotion and partnerships, including engagement with sector leaders such as peak bodies.
Coordination strategies would build on this work, including establishing networks, hosting forums, creating contact lists, supporting development and promoting new evidence and issues, etc. This could include and could be achieved by funding a dedicated position in the ACT to provide tobacco leadership and coordination.
5.3 Sustained and sustainable service deliveryA 2011 review of tobacco management provided within ACT ATOD services revealed a significant lack of tobacco related interventions and support.xviii Further, throughout the Workplace Tobacco Management Project, very limited tobacco management and service delivery has been identified cross-sectorally.
Example of effective service delivery to disadvantaged communitiesxix A successful program that has been active for 11 years is the ʻNo More Boondahʼ program developed by Winnunga Nimmityjah Aboriginal Health Service to provide smoking cessation and support. This weekly support group assists people to identify why they smoke, what triggers their smoking and what strategies can help to avoid or delay their smoking. As well as the support group the program also provides phone support, outreach and follow up for those finding it difficult to attend the weekly session.
This program has been recently strengthened by the Australian Governmentʼs commitment over four years to Tackling Smoking through a National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes. The Winnunga Nimmityjah Aboriginal Health Service was the ACT service to receive this resourcing, which includes a Tobacco Action Worker and a Healthy Lifestyle Worker.
Future directionsThe new national focus on preventative health, including tobacco, creates an important opportunity to develop new and structured resourcing of tobacco service delivery in the ACT. The increasing discussion of tobacco within treatment services
presents an important opportunity for this sector to provide sustainable leadership in tobacco service delivery to disadvantaged groups. However specific incentives, such as funding, will need to be provided in order to achieve this.
5.4 Capacity building and workforce developmentIt is understood that there is no regular training and professional development tobacco program in the ACT. Training is usually purchased from interstate on an adhoc basis. A lack of concerted focus and support for services to become tobacco management capable further sidelines tobacco for other competing priorities. Within existing training opportunities; there is also a lack of focus on disadvantage as it relates to tobacco (with many initiatives focused more broadly at a population level).
Future directionsStrategies that focus on building the capacity of targeted sectors within the ACT are required. Given the complexities of addressing tobacco management with disadvantaged groups, these sectors require initiatives targeted at equipping our workforce to respond to these issues. These strategies could include the development of a sub-workforce with expertise in tobacco management; that could link closely with agreed governance and coordination strategies. This could also include the development, promotion or purchase of relevant information and accredited tobacco training that responds directly to the needs of workers; and can be embedded within the range of workforce initiatives already under way.
5.5 Access to the evidence baseThere are a range of challenges for treatment services and workers to link with the evidence base, making the provision of information and education to dispel myths or address challenges very difficult.
Future directionsIn addition to the provision of training as a means of accessing the evidence base (as per the previous item); workers and sectors (including those in leadership roles) will need support to access emerging evidence regarding tobacco management. This is particularly pertinent as it relates to the practice of worker (for example, implementation of clinical guidelines and assessment tools regarding tobacco). A strategy to do so could involve linking with National Centres of Excellence who have briefs in research dissemination (e.g. the National Centre for Education and Training on Addiction or the National Drug Sector Information Service).
6. Further InformationFor further information please contact Carrie Fowlie, Executive Officer, on (02) 6255 4070 or Email Carrie at Alcohol Tobacco and Other Drug Association ACT.
1 Chronic disease is a “(t)erm applied to a diverse group of diseases, such as heart disease, cancer and arthritis, that tend to be long-lasting and persistent in their symptoms or development. Although these features also apply to some communicable diseases (infections), the term is usually confined to non-communicable diseases” (AIHW 2010:507).
2 The burden of disease and injury is a “(t)erm referring to the quantified impact of a disease or injury on an individual or population, using the disability-adjusted life year (DALY) measure” (AIHW 2010:506).
3 The physical health of people with mental illness is, in general, worse than the physical health of people without mental illness. And in general, people with more severe mental illness have worse physical health than those with less severe mental illness.” (Ragg & Ahmed 2008:19).
i Chronic disease is a “(t)erm applied to a diverse group of diseases, such as heart disease, cancer and arthritis, that tend to be long-lasting and persistent in their symptoms or development. Although these features also apply to some communicable diseases (infections), the term is usually confined to noncommunicable diseases” (AIHW 2010:507
ii Begg, S., Vos, T., Barker, B., Stevenson, C., Stanley, L., Lopez, A.D. (2007). The burden of disease and injury in Australia 2003. PHE 82. Canberra: Australian Institute of Health and Welfare. Retrieved from: http://www.aihw.gov.au/publications/index.cfm/title/10317 (This website link was valid at the time of submission)
iii ACT Health (2010), ACT Alcohol, Tobacco and Other Drug Strategy 2010-2014, Act Government, Canberra
iv Australian Institute of Health and Welfare 2008, 2007 National Drug Strategy Household Survey: State and Territory Supplement, Cat. No. PHE 102. AIHW: Canberra
v ACT Health (2010), ACT Alcohol, Tobacco and Other Drug Strategy 2010-2014, Act Government, Canberra
vi Baker, A. et al. Where thereʼs smoke, thereʼs fire: high prevalence of smoking among some subpopulations and recommendations for intervention. Drug Alcohol Rev 2006;25:85-96
vii Ragg, M. & Ahmed, T. (2008). Smoke and mirrors: a review of the literature on smoking and mental illness. Tackling Tobacco Program Research Series No. 1. Sydney: Cancer Council NSW.
Baker, A. et al. Where thereʼs smoke, thereʼs fire: high prevalence of smoking among some subpopulations and recommendations for intervention. Drug Alcohol Rev 2006;25:85-96.
viii Baker, A. et al. Where thereʼs smoke, thereʼs fire: high prevalence of smoking among some subpopulations and recommendations for intervention. Drug Alcohol Rev 2006;25:85-96.
ix Richter, K. (2006). Good and Bad Times for Treating Cigarette Smoking in Drug Treatment. Journal of Psychoactive Drugs, 38(3), 311-316.
Kerle, C. & Jago, A. (2005). A Non Smoking Policy in a 15 Bed Detoxification Unit. Australian Resource Centre for Healthcare Innovation.
x Campbell, G. & Degendardt, L. (2008). ACT Drug Trends 2007: Findings from the Illicit Drug Reporting System. Australian Drug Trends Series No. 3. Sydney: National Drug and Alcohol Research Centre.
xi Campbell, G. & Degendardt, L. (2008). ACT Drug Trends 2007: Findings from the Illicit Drug Reporting System. Australian Drug Trends Series No. 3. Sydney: National Drug and Alcohol Research Centre.
xii Moeller-Saxone, K 2008, Cigarette smoking and interest in quitting among consumers at a Psychiatric Disability Rehabilitation and Support Service in Victoria, Australian and New Zealand Journal of Public Health, Vol. 32, no. 5, October 2008, pp. 479-481.
xiii Reilly, P., Murphy, L. & Alderton, D. (2006). Challenging Smoking Culture Within a Mental Health Service Supportively. International Journal of Mental Health Nursing, 15, 272-278.
xiv Australian Institute of Health and Welfare 2008, Australiaʼs Health 2008. Cat. no. AUS 99: AIHW: Canberra.
xv Breslau, N & Peterson EL. (1996). Smoking cessation in young adults: age at initiation of cigarette smoking and other suspected influences. American Journal of Public Health 86(20):214-220
xvi ACT Government (2009), ACT Government Budget 2009-2010 ACT, ACT Government, Canberra. For more information please visit ACT Government Treasury website.
xvii Department of Health and Ageing, Population Health Division (2008), National Partnership Agreement on Preventative Health, Australian Government, Canberra.
xviii ATODA (2011), ACT Alcohol, Tobacco and Other Drug Services Directory, June 2011.
xix Media Release. 8 December 2010. From the Hon Warren Snowdown MP, Minister for Indigenous Health – National Workforce Launched to Tackle Indigenous Smoking and Improve Health. For more information please visit ACOSH website.
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