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

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(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.

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.

 

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.

 

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’?

 

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.

 

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

 

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

 

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?

 

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.