9A.1.1 Trends in the prevalence of smoking
More than one quarter (28%) of Australians live in regional and remote areas, and these people often have poorer health and welfare outcomes compared with people living in major cities.1,2 One contributor to these poorer outcomes is the significantly higher prevalence of smoking—see Table 9A.1.1 and Figure 9A.1.1 below. As reported in the 2022–23 iteration of the National Drug Strategy Household Survey, 7% of Australians aged 14 years and older living in major cities smoked daily, compared with 11% of people living in outer regional areas, and 20% of those in remote/very remote areas.3
The prevalence of current smoking (i.e. daily, weekly, or less than weekly smoking) has declined among all geographic groups over time; however, data from the National Drug Strategy Household Survey suggests that the prevalence of current smoking among people living in outer regional and remote/very remote areas is still higher than that of major cities a decade ago3—see Figure 9A.1.1
Data from the Australian Bureau of Statistics also showed a much higher daily smoking prevalence among Australians living in inner regional areas (12.1%) and outer regional and remote areas (15.7%) in 2021–22, compared with those living in major cities (8.9%).4 Research in the US5,6 and Canada7 has similarly shown large disparities in tobacco use between urban and rural populations.
9A.1.2 Contribution of smoking to health outcomes and social inequality
People living in regional and remote areas of Australia report higher rates of some smoking-related diseases. In 2022, people living outside major cities had higher rates of arthritis, asthma, chronic obstructive pulmonary disease, cardiovascular disease, and diabetes.1 Moreover, one study found that smoking was the most important predictor of poor self-rated health among regional Australians.8
Life expectancy also decreases with increasing remoteness. In 2021, compared with all of Australia, people living in remote areas had a mortality rate 1.2 times as high, and people living in very remote areas had a mortality rate 1.5 times as high (both of which are age standardised mortality rates).1 Further, potentially avoidable deaths (i.e. deaths under the age of 75 years from conditions that are potentially preventable through primary or hospital care) increase with remoteness, with the rate of potentially avoidable deaths being 2 to 3 times higher among people living in remote/very remote areas compared to those living in major cities.1
People living in remote/very remote areas often have poorer access to, and use of, health care services, compared with those in regional areas and major cities. They are also less likely to participate in breast and bowel cancer screening, have higher rates of potentially avoidable hospitalisations, and lower access to selected hospital procedures.1 Because health professionals are in such short supply in rural and remote areas,9 it is often difficult to prioritise preventive health activities. The 2012 National Strategic Framework for Rural and Remote Health called for:
- improved access to healthcare
- effective and appropriate and sustainable healthcare delivery
- an appropriate, skilled and well-supported health workforce
- collaborative health service planning and policy development and strong leadership, governance, transparency and accountability.10
This strategy has not been evaluated or updated, and calls have been made to use existing evidence to inform a cohesive, whole-of-system approach and updated national strategy to improve rural and remote health outcomes.11-13
9A.1.3 Explanations for higher smoking prevalence
The higher smoking prevalence among people living in regional and remote areas may be explained by several compounding factors including lower education and socioeconomic levels, physical and social isolation, stress and mental health problems, higher levels of smoking among friends and family, and greater exposure to tobacco marketing.14-16 Adolescents living in rural and remote areas may be particularly susceptible to the initiation of smoking.15,16 A mixed-methods study of adolescents living in rural areas of Australia explored the socio-ecological enablers of smoking and found that the smoking behaviour of friends and peers as well as experiences of stress and mental health problems were the most influential factors for the uptake and continued use of tobacco.16 For a detailed discussion of the influences on the uptake of smoking, see Chapter 5.
Many people living in regional and remote areas experience unique challenges when it comes to smoking cessation. In remote areas there may be a lack of local healthcare infrastructure and staff that are able to provide and deliver cessation interventions. Further, the time and financial burden of travelling to major cities may deter people living in remote areas from accessing specialist healthcare services that might also include cessation interventions.1,17
9A.1.4 Interventions for reducing smoking
To date there has been relatively little research or evaluation of smoking cessation interventions delivered to people living in rural and remote areas, leading to a lack of strong evidence regarding the most effective way to reduce smoking among this group.18,19
The 2022–30 National Tobacco Strategy includes as one of its priority areas strengthening efforts to prevent and reduce tobacco use among populations with a high prevalence of tobacco use, including those living in regional and remote areas. Actions to achieve this include targeted policies and programs; embedding cessation interventions into all forms of social, community and healthcare settings; and increasing awareness of evidence-based cessation support,20 the most effective being a combination of behavioural counselling and cessation medications.21
In Australia, subsidies of cessation medications have clearly been associated with increased access and use, particularly among concession card holders (see Section 9.9). An analysis of Pharmaceutical Benefits Scheme (PBS) data also found that Australian smokers residing in regional and remote communities were just as likely to receive a cessation medication as participants residing in major cities.22 Since 2011, all Australians have been able to access subsidised over-the-counter nicotine replacement therapy patches, and lozenges and gum were also added to the PBS in 2018, though subsequently removed. Bupropion and varenicline are only available on prescription but have been available on Australia’s PBS since 2001 and 2008 respectively (see Section 7.16). It should be noted however, that combination nicotine therapy (a combination of slow-acting medicines such as patches and fast-acting medicines such as gum or spray) is not currently subsidised.
For people who smoke living in regional and remote areas, telephone- and internet-based cessation support may help to overcome limited access to behavioural support from health care professionals. Researchers in the US found that a text-based cessation intervention was feasible, acceptable and easily disseminated to rural older people who smoke.23 A randomised controlled trial of the “Outback Quit Pack” intervention demonstrated that the combination of telephone counselling and mailed nicotine replacement therapy was feasible and acceptable among a sample of rural, regional, and remote NSW residents who smoke.24 Australian researchers have also examined the connectivity of real-time video smoking cessation sessions and telephone calls in rural and remote locations, and found that such interventions were feasible, with minimal connectivity difficulties.25 An evaluation of video counselling among regional and remote NSW people who smoke daily, found that most participants believed the intervention acceptable and helpful, though some aspects were rated less favourably than telephone counselling, suggesting that there may be room for enhancements.26 See Section 7.14 for a detailed discussion of telephone- and Internet-based cessation interventions.
The role of health professionals in rural and remote areas in promoting cessation at every opportunity is important despite lack of services in many regions.5,8,27,28 Interviews with Australian healthcare staff in rural-remote communities identified a number of challenges in implementing smoking cessation programs, including a lack of resources and client access to services; limited collaboration between health services; the difficulty of accessing staff training; high levels of community distress and disadvantage; the normalisation of smoking; and low morale among health staff. In order to overcome these challenges, staff suggested appointing tobacco-dedicated staff; improving health service collaboration, access and flexibility; providing subsidised pharmacotherapies; and boosting staff morale.17 Electronic health records can also be used in rural settings to document smoking and remind healthcare staff of cessation guidelines.29
A small number of smoking cessation initiatives have been trialled in regional areas of Australia. For instance, the “Latrobe Smoking Support Service” provided free nicotine replacement therapy, counselling and peer support to adults who smoke in Gippsland, Victoria. Those involved in the initiative reported high levels of satisfaction with the service, and on average reduced their cigarette consumption, with 24% stopping smoking after six weeks.30 The “10,000 Lives” initiative was launched by Central Queensland Hospital and Health Service in 2017, and focused on maximising the use of existing cessation services available in the region.31 A survey of possible stakeholders in the program (e.g., workers in hospitals, health services and community organisations) found that while nearly half of respondents reported providing smoking cessation support (47.3%), less than a quarter of respondents identified as being involved in the “10,000 lives” program. Those who self-identified as being involved in the initiative were more likely to provide smoking cessation support, highlighting the importance of ongoing engagement with stakeholders to ensure program success.32
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References
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19. Vance L, Glanville B, Ramkumar K, Chambers J, and Tzelepis F. The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses. Int J Drug Policy, 2022; 106:103775. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35772266
20. Australian Government Department of Health and Aged Care. National Tobacco Strategy 2022-2030. Canberra 2023. Available from: https://www.health.gov.au/sites/default/files/2023-05/national-tobacco-strategy-2023-2030.pdf.
21. US Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. 2020. Available from: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.
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24. Guillaumier A, Tzelepis F, Paul C, Passey M, Oldmeadow C, et al. Outback Quit Pack: Feasibility trial of outreach smoking cessation for people in rural, regional, and remote Australia. Health Promotion Journal of Australia, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37968784
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28. Ramsey AT, Baker TB, Pham G, Stoneking F, Smock N, et al. Low burden strategies are needed to reduce smoking in rural healthcare settings: A lesson from cancer clinics. International Journal of Environmental Research and Public Health, 2020; 17(5). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32155775
29. Talbot JA, Ziller EC, and Milkowski CM. Use of electronic health records to manage tobacco screening and treatment in rural primary care. Journal of Rural Health, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34468036
30. Porter JE, Soldatenko D, Borgelt K, Sewell L, Prokopiv V, et al. The Latrobe Smoking Support Service: A quantitative study of participants in a regional area. Health Sci Rep, 2024; 7(5):e2088. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38715723
31. Khan A, Green K, Khandaker G, Lawler S, and Gartner C. How can a coordinated regional smoking cessation initiative be developed and implemented? A programme logic model to evaluate the '10,000 Lives' health promotion initiative in Central Queensland, Australia. BMJ Open, 2021; 11(3):e044649. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33771827
32. Khan A, Green K, Smoll N, Khandaker G, Gartner C, et al. Roles, experiences, and perspectives of the stakeholders of "10,000 Lives" smoking cessation initiative in Central Queensland: findings from an online survey during COVID-19 situation. Health Promotion Journal of Australia, 2022. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35322498