Kevin Rudd has announced a $14.5m injection of funds to lower smoking in Indigenous communities. Indigenous Australians smoke at around 2.5 times the rate of non-Indigenous Australians, with rates being as high as 80% in some communities. That prevalence is one of the key reasons that Indigenous Australians are twice as likely to die within five years of a cancer diagnosis than non-Indigenous people, says the Cancer Council Australia. That's because "cancers caused by smoking are among the most difficult to treat successfully."
Few will see this investment as anything but overdue. But how could it be spent most effectively rather than squandered on legions of endless rounds of tiny interventions?
A paper in last week's Lancet poses an intriguing question.
In a report from Mexico, the Oportunidades program, which sees dirt poor Mexican villagers given "Conditional Cash Transfers" (CCTs) if they comply with a set of requirements such as attending health care, using free food supplements and enrolling kids in school, has seen remarkable improvements in increased height for age, reduced stunting, and reduced obesity. The program across Mexico involves 20 million families and the evaluated component reported in the Lancet saw 90% of families in the trial areas volunteering to participate -- only 1% were refused payment for failing to comply.
Nancy Birdsall of the Center for Global Development has said of CCT interventions "I think these programs are as close as you can come to a magic bullet in development ... They are creating an incentive for families to invest in their own children's futures. Every decade or so, we see something that can really make a difference, and this is one of those things."
Unlike schemes that withhold welfare entitlement payments for failing to meet health and schooling goals, the CCT program is an entirely voluntary incentive scheme. Ethically, the two are therefore miles apart. With smoking, those who want to keep the habit can, while those interested in being paid to stop could sign on and be assisted with evidence-based cessation products to quit (although more than 85% of smokers stop without any formal assistance).
Payment could be staggered to ensure that temporary quitting lasted more than a few days or weeks. Smoking status is easily checked by a simple salivary test for cotinine, a metabolite of nicotine. Health insurance companies have of course been doing something very similar for decades: giving customers massive discounts if they don't smoke.
Simon Chapman is Professor of Public Health at Sydney Uni.
