Mark Wallace-Bell PhD RN Heart Foundation University of Canterbury Health Sciences Centre

Income gaps How many times richer are the richest fifth than the poorest fifth? Wilkinson & Pickett, The Spirit Level Inequality... How much richer are the richest 20% in each country than the poorest 20%?

Wilkinson & Pickett, The Spirit Level Index of: Life expectancy Math & Literacy Infant mortality Homicides Imprisonment Teenage births Trust Obesity Mental illness – including drug & alcohol addiction Social mobility Health and social problems are worse in more unequal countries Index of health and social problems

Social Relations Child conflict Homicide Imprisonment Social capital Trust Bigger income gaps lead to deteriorations in:- Human Capital Child wellbeing High school drop outs Math & literacy scores Social mobility Teenage births Health Drug abuse Infant mortality Life expectancy Mental illness Smoking Obesity

More inequality More superiority and inferiority More status competition and consumerism More status insecurity More worry about how we are seen and judged More “social evaluation anxiety” (threats to self-esteem & social status, fear of negative judgements Valued or Devalued? Smoking as a response to stress caused by inequality?

The cycle of smoking and disadvantage Social disadvantage and deprivation:  adverse circumstances (Unemployment, lone parenthood, transience etc)  stress  isolation  smoking as “normal”  unsafe neighbourhoods  limited recreation Smoking prevalence:  increased smoking  less successful quitting  higher relapse Creates vulnerability to smoking:  as a means of coping with difficult circumstances  as a response to stress and exclusion  as an ‘affordable’ recreation Makes circumstances worse:  less money for essentials  greater financial stress  poorer health and wellbeing Source: Cancer Council NSW

7 Health inequalities in NZ Source: Blakely T, et al. Soc Sci Med 2005: N Z Med J 2008;121:7-11.

8 Changes in life expectancy in 2040 if everyone stopped smoking in Aotearoa by 2020? Compared to the 2006 census smoking rates continuing into the future, if nobody smokes tobacco from 2020 onwards we estimate that by 2040 there will be:  about 5 years of additional life expectancy for Māori (range 2.5 to 7.9 years)  about 3 years of additional life expectancy for non-Māori (range 1.2 to 5.4 years)  and therefore about a 2 year closing in ethnic gaps in life expectancy (range 0.3 to 4.6 years) Blakely, Carter, Wilson, Edwards, Woodward, Thomson, Sarfati. In press. NMZJ

9 20/20 vision on 2040: Achieving health equity Going smokefree as a nation by 2025 is an important step to achieving health equity by 2040

10 Smoker support for change Edwards et al NZ Med J 2009 Views on tobacco control policies

11 An endgame strategy The endgame plan should include:  Community engagement to build support  A clear end date for commercial sales – sinking lid  Clear adjunct policies to reduce both supply and demand of tobacco – to ensure equity and facilitate impact  Built-in reviews at crucial stages (eg, at 1% prevalence for all groups)

12 Community engagement Essential at risk communities part of the process Strategies:  Working with communities  Recognise leadership and advocates for Endgame  Mass media

The Vision Future generations of New Zealand children will be free from exposure to tobacco and will enjoy tobacco free lives

What’s happening  1 January 2012 tax increase  Removal of displays  Increasing smokefree out-door environments  Reduction in supply, improvements in cessation support

Roll on plain packaging!!

Why it matters  Fifty percent of all smokers die from diseases directly caused by smoking – that's means over 300,000 New Zealanders will die before their time.  Of those who die, they die on average 15 years earlier than their non-smoking peers, and most with deteriorating quality of life.  According to the WHO, between 80,000 and 100,000 children worldwide start smoking each day – and approximately a quarter of the children alive in the Western Pacific region will die from smoking.  Smoking is directly responsible for a quarter of all cancer deaths in New Zealand.

The difference you make  The ABC approach is endorsed because of its strong evidence base when linked with the role of health professionals. Evidence shows: –an estimated 20 percent of smokers will go on to make a quit attempt in a six month period following a GP visit –if all smokers were given brief advice to quit then the proportion of smokers making a quit attempt would increase to 25 percent

The difference you make –this can be further increased (by 40 percent) to 35 percent if this advice to quit is followed up with an offer of support to quit –furthermore, people seem to be willing to accept this offer. –The evidence is clear: even just a brief offer of support is enough to prompt people to quit.

The influence you have  You advise just one smoker every day to quit (time taken = 30 seconds)  Over 40 days this would have taken up 20 minutes of your time, but one of those 40 people will quit long term*  Over 1 year and you will have prompted six people to stop smoking, using about 2 hours effort from you  Consider that by investing two hours of your time in that year, you’ve saved three of those people’s lives! *Silagy C, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev

Take home messages  You have an important influence in prompting people to quit  You can help people stop smoking  Medicines work but are not magic cures  Medicines work even better with ‘wrap around’ behavioural support  Don’t give up helping your patients to give up