Tuesday, April 01, 2008

Paying aboriginals not to smoke

Andrew Leigh comments on Simon Chapman’s interesting proposal to pay aboriginals to stop smoking. Why not give such schemes a trial? They are cheaper and probably more effective than active treatment programs including use of NRTs. There is quite a deal of data on incentive effects of such programs in encouraging abstinence among users of illicit drugs such as cocaine.

The main idea is that drug users have short-term time horizons (they are 'hyperbolic discounters') and these programs provide small short-term rewards for remaining abstinent over short periods. This helps deal with short-term incentives to use and helps build up will-power and commitment.

We need to build up an inventory of experience of alternative means of trying to induce aboriginals to control their consumption of harmful drugs. Reading the published literature in this area my impression is that we don't know much. My impression is that there is a lot of verbiage but not much hard evidence and experience. (If I am wrong let me know, please!)

I quote Simon’s argument.

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.

As I have posted before aboriginals have a poor health record partly because of their high incidence of smoking.

This problem has been somewhat overlooked because of an obsession with aboriginal problems with alcohol. Little is known about specific aboriginal smoking issues. Adult males smoke at a much higher intensity of non-aboriginals so targeting aboriginal smokers has a high possible anti-smoking impact. We also know there are severe passive smoking problems in the home. Little is known of Quit campaigns since – there are comparatively few ex smokers among aboriginals so this source of moral pressure to quit is low. There is a much ignorance among aboriginals about the health consequences of smoking and a lack of engagement with 'white-oriented' Quit campaigns both in country and city areas.

I have a postgraduate student writing a thesis on aboriginal smoking issues so this suggestion is of great interest.


jc said...

Andrew Leigh comments on Simon Chapman’s interesting proposal to pay aboriginals to stop smoking. Why not give such schemes a trial?

Harry, smokers lie and cheat. Smokers are even bigger liars than junkies when it comes to a hit.

How would you police it?

Anonymous said...

Yeah, give it a go.

Apply the good old engineering criterion to it: If it works, it's good engineering; if it doesn't, it's nothing but assembled scrap-metal.

It is certainly no sillier and is likely to do far less damage that some of the ratbag ideas that have been chucked at Aboriginal health problems over the past half century.

Who knows? It might work .... but anything is worth a try.

Policing it would be dead easy - this is 2008 and pathology tests [and anti-doping tests too] have come a long way in recent years.

Graham Bell

Yobbo said...

Should we also pay aboriginals to wipe their arse?

We already pay for them to go to school, now people want to pay them to stop drinking, stop smoking, whatever else can we pay them to stop doing? Pay them to stop gambling? Stop masturbating?

This is just getting ridiculous Harry. Not all problems can be solved by throwing money at them.

hc said...

Yobbo, I guess you could alternatively tax dirty arses!

More seriously health costs among aboriginals are high and their health status is appalling. Even from the viewpoint of narrow non-aboriginal self-interest it is a good idea to address these issues.

Its a relatively inexpensive policy with good social payoffs.

jc said...

Great harry. How do i get on this money train?

Anonymous said...

Various parliamentary committees have found that smoking, diet and grog is at the heart of the health problems of Aboriginals.
I remember even Comrade Albanese even coming to this conclusion.

When does personal responsibility come to the fore?

Anonymous said...

Harry, I hate the idea of the government meddling in peoples affairs. Giving aboriginals cash for not smoking??....amazing. Is this the thin end of the wedge? What's next? However, since we the taxpayer (mostly non-aboriginals) are paying for their (very expensive) treatment once they get cancer or numerous other smoking related ailments then maybe on a cost/benefit basis we shld give it a go?? Who knows? Geoff.

Anonymous said...

Anonymous at 1:32pm and Yobbo too:

Yep. You've got the idea.

No. it's not the thin edge of the wedge.

The benefit, in terms of hard cold cash to the taxpayers, far outweighs the costs. It certainly would be a hell of a lot cheaper than, say, paying the Saddam Hussein regime to buy our wheat - or rewarding and licensing scoundrels to plunder people's superannuation funds - or buying slow, horribly expensive, vulnerable fighter aircraft which might be delivered before 2027 if we are lucky.

Oh yes, I almost forgot .... there's a likely benefit - in terms of longer, happier and potentially more productive life - for Aborigines too.

I don't give a damn if it was April Fools' Day on Tuesday. Give it a go.

Graham Bell

derrida derider said...

Surely what's good for the aboriginal goose is good for the white gander. Smoking may be more prevalent amongst aboriginals but the harm done to an individual white smoker and those around him or her is the same as that for an individual black smoker.

Since the problems of targeting and verification will be exactly the same in both cases, why base it on a characteristic such as aboriginality? The Akerlof criteria for the relative efficiency of "tagging" a disadvantaged group for help (as against individual assessment of disadvantage) simply aren't met here. Either pay all smokers not to smoke or none.

Anonymous said...

Derrida Derider:

Agree .... but Aborigines are as good a place to start as any.

Besides, if such a program started among, for instance, wealthy white metropolitan males, you could bet your little pippy that Aborigines out in remote communities would be way, way down the priority list.

No, put the Blackfellas up at the head of the queue for a change.

Graham Bell