Submission on the Draft National Tobacco Strategy 2012-2018

Submission on the draft National Tobacco Strategy 2012-2018

Aboriginal Health & Medical Research Council - June 2012

Introduction and background

The Aboriginal Health and Medical Research Council (AH&MRC) is the peak representative body and voice of Aboriginal communities on health in NSW. NSW has the largest Aboriginal population of any State or Territory with an estimated 152,685 Aboriginal people, comprising 29 per cent of the total Aboriginal population in Australia. The AH&MRC represents more than 50 member Aboriginal Community Controlled Health Services (ACCHSs) and Aboriginal Community Controlled Health-Related Services, and isthe NSW State Affiliate of the National Community Controlled Health Organisation (NACCHO).[1]

The AH&MRC aims to improve the health status of Aboriginal people in NSW through: leading the Aboriginal health agenda for better policies, programs, services and practices; ensuring Aboriginal knowledge informs decision-making processes; and supporting, strengthening and sustaining Aboriginal Community Controlled Health Services. The work of the AH&MRC is undertaken by units including Member Service Support, Workforce Development, Public Health, Mental Health, Applied Research, the Ethics Committee, the Secretariat, and the Aboriginal Health College. The Aboriginal Health College is the Registered Training Organisation of the AH&MRC, and develops and delivers education against national Training Package Qualifications, that targets Aboriginal Health Workers and other health professionals working with Aboriginal people, both in NSW and nationally.

This document is the AH&MRC’s submission on the draft ‘National Tobacco Strategy 2012-2018.’

Aboriginal Community Controlled Health Services and tobacco control

ACCHSs deliver culturally appropriate comprehensive primary health care to their communities. Comprehensive primary health care includes providing preventative health care and programs such as tobacco control activities. ACCHS’s specific roles in tobacco control are many and varied, and include: delivering clinical care to people with tobacco-related illness; running health promotion programs; developing and delivering social marketing campaigns; offering screening and smoking cessation counseling; providing specific supports to assist staff to quit; providing free or subsidized nicotine replacement therapy; developing and promoting smoke free workplace policies; and contributing to community action and local advocacy.

AH&MRC tobacco control

The AH&MRC has been involved in supporting tobacco control efforts in NSW Aboriginal for some years. In 2007 the AH&MRC received funding from the Australian Respiratory Council to lead a two year community-randomised trial, the BREATHE project (Building Research Evidence to address Aboriginal Tobacco Habits Effectively).[2] This trial evaluated the impact of funding and supporting specialised Tobacco Control Workers in ACCHSs to implement tobacco control and smoking cessation activities.

The current AH&MRC Tobacco Resistance and Control Program (A-TRAC) builds on the knowledge and experience of the BREATHE project. A-TRAC is funded by the NSW Ministry of Health, and encompasses a broad range of initiatives which encourage the integration of tobacco control activities into the ACCHS model of comprehensive primary health care. Program components include:

1. Aboriginal Tobacco Resistance Network: This email network links ACCHS staff interested and active in tobacco control with others working in the tobacco control area, informing members about new resources, journal articles, policy and legal developments, and community programs and events.
2. Annual A-TRAC Symposium and Regional Forums:The A-TRAC Symposium is an annual event that brings together ACCHS workers engaged in tobacco control activities to network, share information and promote best practice. The Regional Forums focus on supporting ACCHSs more locally to deliver tobacco control activities, including through upskilling workshops and peer learning.
3. Kick the Habit Campaign: The Kick the Habit campaign[3] involved the A-TRAC team supporting local communities to develop and implement localised Aboriginal social marketing campaigns, as well developing and maintaining a Facebook page to campaign at a state level. This project strengthened capacity of participating Aboriginal communities in developing social marketing campaigns.Films and accompanying resources were produced which target local issues and utilise local community members as champions.
4. Aboriginal Tobacco Resistance Tool Kit: This resource is currently in development and will include a range of strategies and tools to assist ACCHS staff to undertake effective tobacco resistance and control activities, such as developing evaluating local programs and updating smoke free policies.
5. Aboriginal-specific Tobacco Control Training Modules: The Aboriginal Health College is working with the A-TRAC team to develop nationally accredited, culturally appropriateTobacco Control Modules for Aboriginal Health Workers and other ACCHS staff.
6. Aboriginal Quitline Enhancement Project:The AH&MRC and the Cancer Institute of NSW areworking collaboratively to developa culturally appropriate model to improve access for NSW and ACT Aboriginal people to Quitline services.

In addition to the A-TRAC program and BREATHE, the AH&MRC has beenactive in policy development and research. The AH&MRC represented NACCHO on the Tobacco Technical Reference Group that advised the Department of Health and Ageing on the roll out of the Tackling Indigenous Smoking component of the Indigenous Chronic Disease Package. The AH&MRC is also a collaborator on the nationalresearch project, Talking About The Smokes (TATS) that is being undertaken by the Menzies School of Health Research in partnership with NACCHO[4]. See page 6 of this submission for more information about the TATS project.

General comments on the draft National Tobacco Strategy

The AH&MRC commends the significant focus on Aboriginal peoples in the draft ‘National Tobacco Strategy 2012-18.’ Smoking is a major cause of ill-health and mortality in Aboriginal peoples who are twice as likely to be current daily smokers as other Australians.[5] In addition, the AH&MRC commends the emphasis on partnership between ACCHSs and government and non government. ACCHSs play a vital role in tobacco control,which they deliver as part of comprehensive primary health care.

The Strategy would be strengthened by consistency in the terminology used to describe Aboriginal organisations. The Aboriginal Community Controlled Health Sector comprises: Aboriginal Community Controlled Health Services (ACCHSs); Affiliates, such as the AH&MRC; and the National Aboriginal Community Controlled Health Organisation (NACCHO). ACCHSs is used in preference to “Aboriginal medical services” (p43 of the Strategy), and references to “Aboriginal community controlledorganizations” (p28-29 of the Strategy) need to be reserved for contexts in which a broad range of Aboriginal community controlled organizations are being referenced, not just health services. While we note that this may be the intent of the reference in some cases in which it is made, the draft strategy would be strengthened by being specific when it is Aboriginal Community Controlled Health Services that are being referred to, and by overall clarity and consistency.

The Strategy would also be improved by a clearer acknowledgement of the broad range and essential nature of the roles played by the Aboriginal Community Controlled Health Sector in tobacco control at local, state and national levels. NACCHO and Affiliates have a history of strong interest and involvement in tobacco control for Aboriginal communities, including through: supporting service delivery within ACCHSs; developing and supporting health promotion programs; contributing to policy development; supporting government and non government organisations with their tobacco control activities; and developing and delivering education and training.

Response to the target

The Strategy target is outlined on page 18, “to reduce the national adult daily smoking rate to 10 per cent of the population and halve the Indigenous smoking rate by 2018.” We note that for the Aboriginal component the target is expressed with “halve” rather than a percentage and we would recommend this be changed to a percentage (24%) to ensure the Strategy is clear and consistent.

Response to proposed actions to be implemented

• 6.1.2 Continue mass media campaigns targeted to Aboriginal and Torres Strait Islander people including robust evaluation to inform future campaign strategies(p23)

The AH&MRC supports continuing and enhancing social marketing campaigns to reduce tobacco related harm for Aboriginal peoples. However, mass media campaigns need to be complemented by localised social marketing campaigns. Similarly, evaluations of campaigns need to be owned by local communities, and be designed to be consistent with their size and scale. The AH&MRCiswell placed to assist ACCHSs withplanning, delivering and evaluating social marketing campaigns because of our close links and experience working with Aboriginal communities in tobacco control, and this is likely to also be true of Affiliates in other jurisdictions.

• 6.3.1 Continue the investment in, and roll out of existing and planned national and State and Territory programs to reduce Aboriginal and Torres Strait Islander smoking (p28)

The AH&MRC strongly supports the continued investment and roll out of existing and planned national and State programs to reduce Aboriginal smoking.We note that many Aboriginal health programs, including those focusing on tobacco control, currently receive short term funding which limits the effectiveness of the program. Sustainable and long term funding models are required to ensure programs are effective at reducing Aboriginal smoking.

• 6.3.2 Monitor and evaluate the impact of these initiatives and use this data to inform and refine future programs to reduce Indigenous smoking(p28)

The AH&MRC supports monitoring and evaluation of the described tobacco control initiatives to inform and refine future programs. Evaluations would be strengthened if they are informed by the experience and expertise of the Aboriginal Community Controlled Health Sector and undertaken in partnership with Aboriginal communities and their representative organisations.

• 6.3.3 Continue to build tobacco control capacity within Aboriginal community controlled organisations(p 28)

The AH&MRC commends the draft Strategy’s recognition of the vital role of ACCHSs in delivering tobacco control to Aboriginal people and supports the action areas to build theircapacity. The Strategy would be strengthened by clarifying that Aboriginal Community Controlled Health Sector organizations at local, state and national levels all have a vital role to play and required ongoing capacity building efforts.

The AH&MRC strongly recommends that all ACCHSs are offered fundingfor specialized tobacco control positions. The Indigenous Chronic Disease Package supports tobacco control positions in several ACCHSs in NSW. In our experience and through discussion with our members, ACCHSs with designated tobacco control positions are more likely to be delivering free NRT to clients, have operational tobacco control programs, and have comprehensive smoke free workplace policies. Increasing the tobacco control workforce within ACCHSs will contribute significantly to reducing tobacco related harm in Aboriginal communities.

In addition to increasing the specialized tobacco control workforce in ACCHSs, support to build the capacity of NACCHO and Affiliates in tobacco control would also contribute to reducing tobacco related harm in Aboriginal communities. Sustainable funding would enable NACCHO and Affiliates toplay a greater role in policy development and to be able to provide more support to government and non-government organizations through partnerships, as well as enhancing support for ACCHSs in a range of tobacco control areas, including an increased focus on education and training, evaluating programs, and undertaking research.

• 6.3.4 Support Aboriginal and Torres Strait Islander organisations to move towards smoke free workplaces and events(p28)

Supporting ACCHSs and other Aboriginal community organizations to be smoke free workplaces is an important component of the Strategy. Most ACCHSs in NSW have smoke free workplace policies in accordance with OATSIH funding conditions;[6] however the content of these policies varies significantly. The AH&MRC A-TRAC team has been working with member services to assist their development or maintenance of smoke free workplace policies. The AH&MRC and other Affiliates are well placed to continue to provide this support. In addition to support from Affiliates, smoke free workplaces are more likely to be maintained if funded tobacco positions exist.

• 6.3.5 Strengthen partnerships and collaboration between Aboriginal and Torres Strait Islander organisations, governments and non government organisations(p28)

The AH&MRC strongly supports partnership approaches to improving Aboriginal health, and has well developed partnership arrangements with the NSW Government[7] as well as other government and non government organisations working in tobacco control in NSW, particularly the NSW Cancer Council, the Cancer Institute of NSW and the National Heart Foundation. Partnership approaches are essential to ensure the development and evaluation of programs for Aboriginal people areinformed by the expertise of Aboriginal communities, and are therefore appropriate and effective.

• 6.3.6 Continue to provide training to Aboriginal and Torres Strait Islander health workers and other relevant health workers on effective tobacco control interventions (p29)

In addition to increasing the ACCHSs tobacco control workforce, there is a need for Aboriginal specific, accredited training for ACCHS staff and others who work with Aboriginal people. The SmokeCheck program in NSW has been funded by the NSW Ministry of Health and delivered by the University of Sydney until recently. The program has been evaluated, and was demonstrated to increase participant confidence in delivering smoking cessation advice and increase the provision of cessation supports to clients, including culturally appropriate tobacco control resources.[8] We note that the AH&MRC and Aboriginal Health College are not currently included in the list of organisations responsible for delivering this action area. It is our view the AH&MRC Aboriginal Health College and other members of the national network of Aboriginal specific Registered Training Organisations is well placed to deliver appropriate tobacco control training to ACCHSs, and this role needs to be recognized within the Strategy.

• 6.3.7 Deliver best practice screening and smoking cessation as part of routine health service delivery to Aboriginal and Torres Strait Islander clients(p29)

As mentioned above, ACCHSstaff would benefit from further training and support in delivering best practice screening and smoking cessation to Aboriginal clients. Affiliates are well placed to support ACCHSs to deliver screening and cessation supports. In NSW, ACCHSs would benefit from the SmokeCheck program being accredited and delivered by the AH&MRC with sustainable funding to do so.

• 6.3.8 Encourage Aboriginal and Torres Strait Islander people to access subsidized NRT, identify any barriers to access, and develop strategies to overcome these barriers(p29)

In the draft Strategy, the Commonwealth government is identified as the organisation responsible for encouraging Aboriginal people to access subsidized NRT. We recommend that the Aboriginal Community Controlled Health Sector also needs to be involved in this effort, in a partnership approach, particularly in research or other efforts to identifying barriers to accessing NRT and developing strategies to overcome these barriers.

• 6.3.9 Encourage and support Aboriginal and Torres Strait Islander pregnant women and their families to quit and provide messages about the harm associated with ETS exposure (p29)

Addressing environmental tobacco smoke exposure in Aboriginal communities is an important component of the Strategy. Many ACCHSs and the AH&MRC have experience in initiatives specifically targeting ETS. Affiliates would be important partners in delivering this action area because of the strong links with, and trust from, Aboriginal communities.

• 6.3.10 Enhance social marketing campaigns for Aboriginal and Torres Strait Islander people using effective mainstream campaigns complemented by Indigenous-specific campaign elements and local community-specific campaigns (p29)

We note that there is some inconsistency in the action areas outlined in 6.1.2 and 6.3.10 and recommend that the Strategy clarifies the action areas addressing social marketing campaigns for Aboriginal people. Please refer to our response to action area 6.1.2 on page 3.

• 6.3.11 Improve understanding of barriers to successful smoking cessation and uptake in Aboriginal and Torres Strait Islander populations and any areas in which they differ from those in the general population (p29)

The AH&MRC supports action to increase understanding of the barriers to smoking cessation and uptake in Aboriginal communities. However, in addition to identifying such barriers, the AH&MRC would strongly support the action area including developing strategies to address these barriers.

• 6.4 Strengthen efforts to reduce smoking among people in disadvantaged populations with high smoking prevalence (p29)

The Strategy notes that Aboriginal people are significantly over-represented in the prison setting. A specific action area addressing culturally appropriate tobacco control initiatives for Aboriginal people in custody would contribute to reducing tobacco related harm in the Aboriginal population, and is recommended.

• 6.8.2 Enhance Quitline services for pregnant women (in particular Aboriginal and Torres Strait Islander women) including call back services and feedback to obstetricians, GPs and midwives and Aboriginal health workers (p42)

Please see the section below regarding action area 6.8.3 for our response to Quitline services.

• 6.8.3 Enhance Aboriginal-specific Quitline services including call back services and feedback to Aboriginal health workers(p42)

In AH&MRC discussions within NSW Aboriginal communities, doubt has been expressed about the potential acceptability and effectiveness of the Quitline model for Aboriginal people, with strong preferences being expressed for face to face smoking cessation support over telephone services. In light of these views, it will be particularly important that proposed investments for further enhancing Quitline services for Aboriginal people are rigorously and appropriately evaluated, in partnership with Aboriginal communities and their representative organisations. In addition, the Strategy would be improved by more clearly acknowledging the potential value of a role of the AH&MRC and other Affiliates in efforts to enhance the effectiveness of Quitline services for Aboriginal communities.