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.