When it comes to smoking the good news is that Australia has one of the lowest smoking rates in the world. There are a few reasons for this, and one should acknowledge the role of the activists and campaigners from BUGA UP in the 1980’s. BUGA UP stands for Billboard Utilising Graffitists Against Unhealthy Promotions. These activists armed with spray cans and a sense of humour proved to be influential. Some of them went on to be professors and politicians and an example of their work is below:
Australia has gone on to lead the world in the plain packaging of cigarettes.
But perhaps most importantly Australia has taxed cigarettes so that 70% of the price is tax. This means that Australia has some of the most expensive cigarettes in the world. A comparison below in $USD.
However, smoking rates are uneven across the country with high smoking rates in rural areas and lower rates in urban areas. For example, there is a 5% smoking rate in St Ives in Sydney and a 30% smoking rate in Moree in Western NSW. Aboriginal smoking rates are also extremely high at 27%.
Smoking for an individual has the most profound adverse health impact out of any behavioural risk factor. For example, a USA study published by the National Academy of Sciences compared factors such as income, unemployment, education, and depression on mortality, and this showed that smoking is has the greatest impact. And to really make the point, the confidence interval for smoking doesn’t even overlap with the second worst risk factor, and then out of the sixty risk factors, being an ex-smoker comes in again at number six on the list.
Smoking makes a big contribution to the fact that males living in very remote areas have a mortality rate 1.5 times higher than those living in major cities. Females living in very remote areas have a mortality rate 1.7 times higher than those living in major cities. The gap in Australian life expectancy between the city and the country is between 4 and 9 years.
As well as the health impact there is an economic burden on rural communities. To estimate the financial cost of smoking for an individual I have used $35 AUD as the cost of a pack of 20 cigarettes, and we know the average Australian smoker consumes 86 cigarettes per week. This gives a total cost of smoking as $7800 per annum, and because 70% of this is tax, there is an extra $5500 of tax paid per smoker per year. If you are on the Australian median income of $48k a year, this is equivalent to an extra 11% tax on your income.
When we consider the whole Australian population, rural communities have a 60% higher rate of smoking in relative terms, which is an 8% higher incidence in absolute terms (i.e. 22% compared to 14%). There are 6.7 million Australians living in rural communities and this means an additional 500,000 rural smokers, which is an additional $2.9 billion of cigarette taxes being paid by rural Australians. To put this in perspective the estimated total taxes collected from cigarettes is $14 billion. This compares to the $50 billion we spend annually on public hospitals and the $10 billion on GP Medicare rebates.
As a doctor I am supportive of making cigarettes expensive and pushing down our smoking rates. However considering the taxes being levied and their poor health status, are rural communities getting the health funding they deserve?
The answer is yes and no, but there is more NO than YES in this.
There is $125 million in additional Medicare bulk billing support through the higher rural bulk billing incentives, but overall there is a rural Medicare underspend of $881 million. The National Rural Health Alliance estimates there are rural underspends in dental ($340m), pharmacy ($850m), aged care ($500m) and allied health ($260m). The only rural overspend is $829m on public hospitals. This overspend is probably not surprising to those that work in rural hospitals, as they take on a wider community role and are not able to get the same economies of scale.
Overall, this adds up to a $2 billion rural health underspend.
Australia is winning the smoking war, but many rural communities have been left far behind. This means rural communities have higher smoking related mortality, are being taxed heavily for this, and to add insult to injury are being under funded for their health services.