Targeting Tobacco An alternative approach Carolyn Baker

Why another smoking project? The Targeting Tobacco project aims to contribute to reducing Tasmanian smoking rates to 15% by 2016. The current adult smoking rate for Tasmanians (daily & occasional) is 21.7% and is declining .. Daily and occasionally smoking rates as defined in the Australian Health Survey 2011/12.  BUT

Smoking rates are increasing for some People in lower socio economic groups have higher smoking rates than people in higher socioeconomic positions AND People facing multiple disadvantages have the highest smoking rates of all. This was initially picked up through an economic impact study of smoking conducted by Cancer Cancer NSW in 2004/5. More recently the Australian National Preventative Health Agency conducted research in 2013 on the evidence of smoking and disadvantage.

Australian National Preventative Health Agency 2013 Messages in mainstream media have contributed to declining smoking rates. But these messages have not penetrated certain sectors of the community where smoking remains prevalent.

Tobacco is a social justice issue 1 in 2 smokers will die from smoking Higher prevalence of smoking by disadvantaged groups means that people start smoking earlier smoke for longer smoke more heavily fewer attempt to quit Higher prevalence = higher level of health problems + impact on disposable income Tobacco use is a social justice issue Facilitator Presentation It means that smoking is ,ore common, more an accpeted part of these peoples lives.   In summary, there are very high rates of smoking among our most vulnerable community members and among people from a range of disadvantaged circumstances. These higher smoking rates are produced by higher uptake, higher dependence, longer smoking careers and lower quit success. Higher smoking prevalence results in greater health and financial problems for these disadvantaged people. Half of smokers will die because of their smoking. Those households with smokers will experience hardships because of financial stress, meaning they may go without food, household items or they may not be able to pay rent as they spend money on their tobacco smoking habit. [Sources: Siahpush., (2003); Doll et al., (2004)]

Financial impacts of smoking In Australia among smoking households 11% suffer severe financial stress poorest households spend 20% of their income on tobacco children twice as likely to go hungry less income for housing/rent higher absenteeism from work Sources: Siahpush, Borland & Scollo (2003); Siahpush,Spittal & Singh (2007); Siahpush, Yong, Borland, Reid & Hammond (2009); Scollo & Winstanley (2008)] Smoking and financial stress Facilitator Presentation   As mentioned earlier, in 2004, Cancer Council NSW commissioned a study into the economic impact of a reduction in smoking in NSW. An incidental finding of that report was that the most disadvantaged households stood to gain the most from a reduction in smoking rates, not only in terms of health but also financially. In Australia: 11 % of smoking households suffer severe financial stress and at times have been unable to afford to heat their homes and have gone without meals. 58% of smoking homes report not having enough money for holidays, nights out with the family, or for buying gifts for their children. Smoking households on low incomes are more likely to experience these difficulties. Smoking can make food difficult to afford. Smoking households are more likely to have trouble paying for food for their families. Children living in smoking households are twice as likely as other children to experience food insecurity (being hungry or regularly missing meals) and 3 times as likely to experience severe food insecurity. Children who experience food insecurity are at a higher risk for mental or social disabilities, and a poorer quality of life. They score lower on academic tests, miss more days of school and have more difficulty with interpersonal relationships. Smoking can affect housing. Smoking reduces household income making it harder to pay rent or buy one’s own home. Smoking can affect work. Smoking may cause people to take more time off work because of the health impacts of their smoking. This limits income and can make it harder to find or keep work. [Sources: Siahpush, Borland & Scollo (2003); Siahpush,Spittal & Singh (2007); Siahpush, Yong, Borland, Reid & Hammond (2009); Scollo & Winstanley (2008)]

Benefits of quitting Quitting smoking brings immediate financial benefits and reduces suffering from financial stress by 42%. A pack-a-day smoker can save more than $5000 a year by quitting.   Tackling Tobacco Program NSW indicates community sector clients (with an average income of $400 or less) spent around $64 per week on smoking. Quitting smoking potentially enables people on low incomes to increase their disposable income    Source: Cancer Council NSW (2012) Quitting smoking brings immediate financial benefits and reduces suffering from financial stress by 42%. A pack-a-day smoker can save more than $5000 a year by quitting.   Tackling Tobacco Program data indicates community sector clients (with an average income was $400 or less) spent around $64 per week on smoking. Quitting smoking potentially enables people on low incomes to better afford essential items like household bills, food and clothing. Quitting also provides more money for little life-luxuries like family outings, going to the movies, or even buying a coffee. For parents that do quit, this also means there will be less overall stress in the home, benefiting themselves and their children. The iCanQuit website: http://www.icanquit.com.au/ calculates how much money can be saved by quitting. Further information is available in the handouts. It may be something that can be done together with a client when talking about the financial issues associated with smoking and benefits of quitting. [Source: Cancer Council NSW (2012)]

A vicious cycle Social disadvantage and deprivation Makes circumstances worse Creates vulnerability to smoking Smoking prevalence Slide 21 – Smoking and disadvantaged groups Facilitator Presentation   Social Disadvantage and Deprivation:  adverse circumstances (unemployment, lone parenthood, homelessness, etc.)  stress  isolation  smoking as “normal”  unsafe neighbourhoods Creates Vulnerability to Smoking:  as a means of coping with difficult circumstances  as a response to stress and exclusion  as an ‘affordable’ recreation Smoking prevalence:  increased smoking  less quitting  higher relapse Makes Circumstances Worse:  less money for essentials  greater financial stress  poorer health and wellbeing [Source: ‘The Relationship Between Smoking and Disadvantage and What Community Services Can Do’. Cancer Council NSW and Association of Children Welfare Agencies fact sheet, 2008. http://www.cancercouncil.com.au/wp-content/uploads/2011/11/CAN3248-The-relationship-between-smoking-and-disadvantage-with-references.pdf]

Aim of Targeting Tobacco Project Reduce smoking-related harm amongst disadvantaged groups by Building capacity of social and community service organisations to Make smoking care part of usual care Support clients to quit

What we have done to date State-wide survey of Tasmanian community service organisations in April 2014 Investigated how social and community service organisations address smoking with their clients and staff. To read the final report go to Quit Tasmania website http://www.quittas.org.au/resources- professionals/targeting-tobacco To identify current smoking attitudes, organisational policies and practices currently in place throughout the sector.

Results Over 76 responses to the survey were received from 44 different community service organisations around the state. Half the respondents were actively engaged as either case workers 17 (24%) or support workers 19 (26%) Proportion of smokers working in the community services sector daily and occasional was estimated at 27% Community workers believed more than half their clients smoked Clients accessing community service organisations present with numerous social and health issues as seen in Figure 1. Survey responses show 39 (54%) view their clients as being from a low socioeconomic status and 33 (46%) have clients diagnosed with a mental disorder. The ABS defines socioeconomic disadvantage in terms of people's access to material and social resources as well as their ability to participate in society and all classifications below could be included in this term.

Smoking Policies Table 1. Organisation policies 85% of respondents stated their organisations had smoking policies Most policies covered smoking in buildings (90%) and vehicles (76%), Fewer policies exist around staff and client smoking on home visits, accompanied outings and in temporary accommodation. Please indicate what the policy relates to (tick all that apply):   Response % Response Count Smoking inside the building and offices 90% 65 Smoking in work vehicles 76% 55 Staff smoking with clients 44% 32 Staff smoking on home/client visits 39% 28 Smoking by clients on accompanied outings 21% 15 Smoking by clients in temporary housing/accommodation 19% 14 Provision of support for staff and /or clients to quit smoking 35% 25 The survey indicated 85% of organisations have smoking policies, however these policies relate mostly to compliance with legislation (e.g. smoking inside office buildings) and smoking work vehicles. Notably, fewer policies existed that addressed clients who have access to temporary or other accommodation provided by the organisation, and are visited at home by staff or accompanied by staff on outings.

Organisation Practices 47% respondents indicated their organisational practices did not include recording a client’s smoking status on their files 32% of community service workers never ask clients if they are interested in quitting or cutting down their smoking 39% never record quit smoking attempts 44% never include quit smoking plans as part of a service to clients 26% never refer clients for additional quit smoking support. The survey also indicated current practices around recording smoking status, quit attempts, advice provided and referrals is limited across community sector organisations with 32% never asking clients if they are interested in quitting or cutting down, 39% never recording quit smoking attempts and 44% never including quit smoking plans as part of a service to clients and 26% never referring clients for additional quit smoking support. Opportunity exists for organisations to incorporate changes in practice to make smoking a part of normal casework supporting the client as 62% believe smoking care should be part of the normal care offered to clients. The Relationship Between Smoking and Disadvantage and What Community Services Can Do’. Cancer Council NSW and Association of Children Welfare Agencies fact sheet, 2008. http://www.cancercouncil.com.au/wp-content/uploads/2011/11/CAN3248-The-relationship-between-smoking-and-disadvantage-with-references.pdf

Attitudes to smoking 74% of community service workers believed smoking ads to their clients’ disadvantage. 75% of respondents believed smoking clients should receive support to quit smoking 62% of respondents believe smoking care should be offered to clients by their organisation 40% believed the organisation currently supported staff to be able to provide this assistance Seventy four per cent of community workers believed smoking added to their clients’ disadvantage. This offers an avenue for future efforts by the sector to take on a bigger role as advocates for quit smoking support by educating workers and clients about the links between smoking and continued disadvantage and in providing quit smoking advice and practical assistance to support clients reduce their reliance on smoking.

Skills and confidence to address smoking How confident are you about asking the following? Not at all % Unsure Moderately confident Extremely confident % Asking someone about their smoking 4 5 29 33 Providing brief advice and support for someone wanting to quit smoking 7 6 35 24 Who to refer clients to when they are interested in quitting smoking 34 31 Understanding the short and long term health consequences of smoking 2 23 47 Understanding and promoting the benefits of quitting 41 Understanding the process of nicotine addiction, quitting and relapse 3 11 28 Understanding the impact of second hand smoke 39 Understanding (NRT) and cost 14 19 22 17 Staff training on smoking cessation had occurred in 24% of organisations in the last 12 months While community workers were confident in discussing smoking with clients, the confidence levels of staff in knowledge about ways to quit using nicotine replacement therapy and its cost was low. This reduces the ability of staff to inform clients about current ways they can go about quitting and in turn restricts opportunities for staff to offer a meaningful brief smoking intervention to clients. The survey also revealed that while community workers were confident in discussing smoking with clients, the confidence levels of staff in knowledge about ways to quit using nicotine replacement therapy and its cost was low. This reduces the ability of staff to inform clients about current ways they can go about quitting and in turn restricts opportunities for staff to offer a meaningful brief smoking intervention to clients.

“what skills, support and resources are needed to better enable organisations to support clients and staff interested in quitting smoking?” Training and education Review community organisation smoking policies Improve client documentation Review smoking resources Literacy issues were identified as a weakness for many people accessing community services. Easy to read, visual materials would be of use in discussing smoking with clients. In gauging the perceptions from community workers about their clients ability to read fluently and comprehend written text, 25 (39%) believed most clients they see would struggle to read fluently and comprehend written text while others thought 42 (58%) clients they see experience some difficulty with literacy.

The next 6 months Quit Tasmania is offering free 1 hour briefings to community service organisations keen to update staff on ways to support staff and clients interested in quitting. Sessions will be targeted to the population groups with whom organisations predominantly work Briefings will be held August to December 2014. A Targeting Tobacco Community Worker Kit of helpful resources is being developed Evaluate workers confidence and attitudes and then work towards implementing a change in recording clients smoking status.

For more information Carolyn Baker Cancer Council and Quit Tasmania Ph: 62428109 Email: cbaker@cancertas.org.au Visit: www.quittas.org.au