Health Priorities in Australia Lung Cancer

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					Health Priorities in Australia – Lung Cancer
                             By Emily Fraser

   1. Why this National Health Priority Area (NHPA) should be one of
      the six most important.

Introduction on National Health Priority Areas

In 1993 the health ministers from the Commonwealth government and all
state and territory governments met with the purpose of providing some
common direction in national health and reducing any existing inequalities.
At the National Health Summit the health ministers agreed that national
goals and targets should be stated and form the basis of a national health
policy. It was decided that they needed to focus more on prevention and
improving health rather than just curative measures and health care
services. It was decided that there would be six priority areas. These are:
    Cardiovascular health;
    Cancer;
    Injury prevention and control;
    Mental health;
    Diabetes; and
    Asthma.

The selection of these priority areas were based on six specific criteria:
    Principles of social justice;
    Priority population groups;
    Prevalence of condition;
    Costs to individuals;
    Costs to the community; and
    Potential for change. [1]
Of these National Health Priority Areas cancer is a widespread and
significant illness in our community.

The NHPA Cancer Control initiative focuses on eight different types of
    Lung cancer;
    Melanoma;
    Non-melanocytic skin cancers;
    Colorectal cancers;
    Prostate cancer;
    Non-Hodgkin‟s lymphoma;
    Cervical cancer;
    Breast cancer. [2]
Of these cancers this paper will focus on lung cancer.
What is Lung Cancer?

Lung cancer is an abnormal growth of cells of your lung. It is called cancer
cells or malignant cells when these cells multiply uncontrollably. Malignant
cells can often grow into a lump or a tumour. [3] People with lung cancer
may experience the following symptoms:
     Recurring chest infections;
     Dramatic weight loss;
     Swelling of face and arms;
     Breathlessness;
     Chest pain;
     Coughing or spitting up blood;
     Fatigue;
     New or altered cough;
     Shortness of breath;
     Difficulty in swallowing. [4,5]

Cigarette smoking is the major cause of lung cancer with up to 90% of lung
cancers caused by smoking. The longer a person has been smoking and
the more they smoke, the greater their risk is of being diagnosed with lung
cancer. [6]
Picture: the lung of a smoker


Priority Area Selection Criteria

Principles of social justice – Survival and good health should not depend
on the socio-economic level of people in the community. The Australian
government through its Medicare system has accepted this principle by
providing a medical „safety net‟ for all Australian citizens. Significantly, lung
cancer is more prevalent among lower socio-economic groups for men,
mainly because smoking is more common these groups. As a result men
in the lower socio-economic groups have more of a need for medical care
because of lung cancer. Therefore lower socio-economic groups are a
greater burden on the health care system, with respect to lung cancer,
than other groups. It is for exactly this type of inequity that Australia‟s
Medicare „safety net‟ was developed[8].

Priority population groups – The priority population groups experience
unnecessarily high incidences of lung cancer. For lung cancer the
identified priority group is men in low socio-economic groups.

Prevalence of condition – Another basis for selection of a priority area is
the number of cases of lung cancer. Lung cancer is the most prevalent
cancer causing death in men and the second most prevalent cancer
causing death in women. The incidence of lung cancer cases in Australian
men is 62 per 100, 000 people, with women being slightly less than half
this rate.

Costs to individuals – There are two types of cost that individuals must
bear when suffering with lung cancer. These are financial costs and
lifestyle costs which include social isolation, hospitalisation and lack of
mobility and pressure on relationships and family. With respect to lung
cancer perhaps the most serious cost is a lifestyle cost and frequently
resulting in death.

Costs to the community – Costs to the community are generally measured
financially. However, some community costs are difficult to measure. The
overall financial cost to the community for priority illnesses is $30 billion.
Lung cancer makes up a significant portion of this. Other community costs
such as loss of income and workplace productivity as a result of illness or
premature death, travel cost of patients, and the cost of caring for an ill
person at home are difficult to measure financially but still have a dramatic
impact on the community.

Potential for change – There is significant potential for change in the
lifestyle related areas. The incidence of priority illnesses and especially
lung cancer can be reduced by making behavioural and environmental
changes. For example, if young people were encouraged to stop smoking
this would reduce the incidence of lung cancer mortality later in life.
Another example involves the prevalence of passive smoking. Significant
progress has been made in this area through eliminating smoking in pubs,
restaurants, offices, transport etc.

In the period 1999 to 2003 cancer was the second leading cause of death
in Australia for both males (29.9%) and females (24.7%), behind
cardiovascular disease. By 2004 this had increased in males (31.3%) and
in females (25.9%) with lung cancers at 6.9% in males and 3.9% in
females. Lung cancer is the most prevalent cancer causing death in men
and the second most prevalent cancer causing death in women. Even
though lung cancer is the leading cancer causing death, it is only the fifth
most commonly diagnosed cancer in Australia. This shows that it is a very
lethal form of cancer. Clearly lung cancer should be targeted as one of
Australia‟s National Health Priorities [9,10].

New cases of lung cancer currently occur in males at more than twice the
rate among females: 62.1 per 100,000 compared to 27.4 per 100,000.
Lung cancer incidence increases with age, with the highest incidence in
those aged 75-79: 450.4 per 100,000 males and 156.4 per 100,000
females in 2000. [5]

The graph below shows the number of lung cancer deaths in the Australian
population by age group, per 100,000 people. The graph shows that there
are negligible lung cancer deaths before the age of 50 for both men and
women. After the age of about 50 the incidence of death from lung cancer
rises rapidly. The graph shows that more men die from lung cancer than
women and for age groups above 70 more than twice as many men die
from lung cancer than women.

      Graph 1 - Lung Cancer deaths in Australian population [11]
The five-year survival rate for lung cancer has been very low in the past,
but is slowly improving. For lung cancers that were diagnosed between
1980 and 1984, the five-year survival rate was 9% in males and 11% in
females. The improvement is shown in the lung cancers that were
diagnosed between 1994 and 2000, where it was 12% for males and 15%
for females [11].

Passive smoking (breathing in other people's tobacco smoke) also
increases a person‟s risk of getting lung cancer. In 1998, the UK
Government‟s Scientific Committee on Tobacco and Health after reviewing
evidence from many reliable sources concluded that with long-term
exposure to ETS (environmental tobacco smoke), the increased risk of a
never-smoker being diagnosed with lung cancer is in the order of 20–30%.

Doctors, dentists and lawyers and those of similar professional status had
the lowest death rate from lung cancer, at 19.9 per 100,000. Teachers,
scientists, managers, executives, farmers and those of similar status had a
rate of 35.3 per 100,000. Technicians, clerical workers, salesmen, farm
labourers, mechanics and those of similar status had a rate about twice
that of the lowest group, at 41.3 per 100,000. Builders' labourers, miners,
storemen, council labourers, domestic service workers and those of similar
status had the highest death rates from lung cancer, around three times
that of the lowest group, at 54.7 per 100,000. [12]

Lung cancer is the leading cause of death of men and the second in
women. Even though the incidence of lung cancer only ranks fifth on the
list its death rate is the greatest of any of the cancers. Therefore, it is clear
that lung cancer should be a National Health Priority area in Australia.

   2. Identify what are the determinants for better health and what
      are the causes of current inequalities.

Determinants for better health

The determinants for better health include the following:
Socio-economic status – Statistics indicate that people with higher socio-
economic status have a lower incidence of lung cancer and those with
lower socio-economic status have a higher incidence of lung cancer.
Therefore if the socio-economic status of those most at risk of lung cancer
is improved then the incidence of lung cancer should be measurably

Education – Highly educated people such as doctors, dentists and lawyers
have a much lower incidence of lung cancer than those who aren‟t as
educated such as builders, labourers, miners, storemen and council
labourers. One of the benefits of increasing funds in education is to see a
reduction in the incidence of lung cancer.

If more people are educated about the risk factors of lung cancer then it
would be expected that there would be a reduction in the incidence of lung

Employment – Unemployment and low-income employment are
contributing factors to lower socio-economic status which is directly related
to higher incidence of lung cancer. Therefore if we can reduce
unemployment and increase standard of living for everyone in the
community then we should expect a reduction in the incidence of lung

Ethnicity – Statistics indicate that migrants from the Middle East and Asia
have a lower incidence of lung cancer than Australian born people. There
are no actions that can be taken in this area that could be recommended.

Economic Development – As a country becomes more economically
developed there are fewer „blue collar‟ workers. These „blue collar‟ workers
generally smoke more and have a higher incidence of lung cancer. So as
the country becomes more developed and there are not as many of these
people the incidence of lung cancer is lowered.

Gender – The incidence of lung cancer is significantly higher in males than
in females. The reasoning for this is because there are more male
smokers. Although there are currently more males with lung cancer the
incidence is gradually lowering, whereas the incidence is becoming higher
in women over time. If women were more educated about the effects of
smoking on their health perhaps this trend could be stopped.

Age – There are very few lung cancer related deaths before the age of
fifty. After this age the death rate climbs very rapidly. It is important to
educate people when they are young about the risk factors of lung cancer
because this is when they start smoking and become addicted. It is very
unlikely that a person would develop lung cancer if they did not smoke.

Location – There are no obvious links between location and the incidence
of lung cancer [13]. Although people who live in rural areas may be
disadvantaged when it comes to treatment for lung cancer. The medical
facilities that are available to people who live in rural areas could be
improved. This would make sure that people who live in rural areas would
get the health care that they need.

Heredity – While lung cancer has mainly been associated with
environmental factors, there is emerging evidence that indicates that some
people have a genetic predisposition for the disease. There is ongoing
research that will either prove or disprove this theory and necessary action
will take place. [14]

Causes of Current Inequalities

It is useful to determine the causes of inequalities between different groups
of the community with respect to lung cancer. The information can be used
to help define the problem and therefore help to reduce the incidence of
lung cancer.

Gender – Epidemiological research has shown that there is a higher
incidence of lung cancer in men than women. In fact after the age of 55
there is about double as many men who have lung cancer than women.
This can be put down to the fact that there are more men smokers than
women. Although currently more men have lung cancer than women there
is also research to indicate that the incidence has been lowering over the
past two decades in men. This can be put down to improved education and
effective health promotion strategies. The opposite is happening in women,
the incidence of lung cancer is increasing. The changing role of women in
the workplace might be a cause for increase in lung cancer. Women are in
more „powerful‟ roles in the workplace which can lead to higher stress
levels than they have had to deal with before. Some people deal with
stress by smoking which can often lead to lung cancer. The media may
also play a negative role through the promotion of attractive females
smoking. The media also promotes the link between smoking and weight

Age – Very few people under the age of 45 suffer from lung cancer. After
this age the incidence rises dramatically. The reason for this inequality is
that lung cancer doesn‟t affect people until later in life. A person can
smoke for their whole life and have no negative effects until they are older.

Location –There are great inequalities between treatment of people in
urban and rural areas. Health services are nowhere near as advanced as
they are in major cities. People who live in rural areas would need to travel
to the city to receive treatment for their cancer.

Socio-economic Status – People with high socio-economic status would be
able to receive better treatment for lung cancer than people with low socio-
economic status. This is simply because they have more money to be able
to afford private health care.
   3. Describe how the five action areas of the Ottawa Charter
      interact to help address the problem.

Introduction to Ottawa Charter

In 1978 the World Health Organisation (WHO) and United Nations
International Children‟s Emergency Fund (UNICEF) held a major
conference on health care. Representatives from over 130 nations
attended this conference, and the main outcome of was the Declaration of
Alma Ata. This declaration outlined the inequalities that exist between
different nations as a result of a combination of economic, political and
cultural factors. The declaration encouraged action in areas such as equity
and social justice, intersectoral collaboration, community participation and
empowerment and health promotion.

In 1979 the World Health Assembly adopted a new slogan „Health for All
by the Year 2000‟. This slogan was selected to try to bring to people‟s
attention the inequalities that exist in health within and between different
nations and the need to place adequate health services within reach of

There was another conference in 1986 in Ottawa. This conference
attempted to build on the progress made through the Declaration of Alma
Ata and in an attempt to achieve health for all by the year 2000. A
document titled the Ottawa Charter for Health Promotion was produced at
this conference. This document defined five specific areas for health
promotion action. These are:
      1. Developing personal skills
      2. Creating supportive environments
      3. Strengthening community action
      4. Reorienting health services
      5. Building healthy public policy

Lung cancer is a major problem in our society and the Ottawa Charter was
designed to help problems such as this. The five action areas are
explained below with relevant examples to lung cancer.

Developing Personal Skills

“Health promotion supports personal and social development through
providing information, education for health and enhancing life skills. By so
doing, it increases the options available to people to exercise more control
over their environment, and to make choices conducive to their health”.
This action area of the Ottawa Charter aims at encouraging people to be
more independent and self-supportive. These two things are instrumental
in developing the skills necessary for a person to live a normal healthy life.
People not only need to be encouraged to make healthy choices but they
need to be taught how to do this and the consequences of making bad
health decisions.

To develop personal skills a person must be educated. So this action area
has a lot to do with educating people about the risk factors of lung cancer
so that they are able to take control over their own health.

Lung cancer is a preventable disease. Statistics indicate that cigarette
smoking directly causes 90% of all lung cancers. The other 10% of lung
cancers are from exposure to asbestos fibres, other carcinogenic
chemicals and passive smoking. All of these risk factors are preventable
and this area of the Ottawa Charter aims at educating people about this.

This area of the Ottawa Charter would aim at educating people so that
they can be more assertive. This is an important life skill and would give
people the knowledge to know how to say no to smoking cigarettes.

People need to be educated about passive smoking. Just because a
person may not be smoking a cigarette personally does not mean that the
toxic smoke will not harm them. If people are educated about passive
smoking they may not tolerate people smoking around them. This would
not only stop them from possibly developing lung cancer later in life but it
may discourage people around them from smoking.

Some people in our society work daily with carcinogenic chemicals and
asbestos fibres. These people must be educated about their line of work
and how it could possibly lead to cancer later in life.

This action area is vital in promoting healthy lungs for every individual.

Creating Supportive Environments

“The overall guiding principle for the world, nations, regions and
communities alike, is the need to encourage reciprocal maintenance – to
take care of each other, our communities and our natural environment”.

It is very important for people to have a supportive environment where they
are encouraged in a positive way. People should feel supported both at
home and at work. This is what this action area of the Ottawa Charter
strives to achieve.
Over the past decade there have been campaigns that aim at discouraging
smoking around young children. Such as “Car and home smoke free
zone.” This has to do with the fact that people can develop lung cancer
from passive smoking. It is important that children don‟t have people that
smoke around them for two reasons. The first being that it is bad for their
health and they could develop lung cancer and other illnesses. The second
reason is that children are very susceptible to influence and smoking
around them may influence them to take up smoking.

Government initiatives such as the „Quitline‟ and the “Quit” website are no
judgement environments where people can get help to quit smoking.

Restaurants, offices, public places, beaches and ultimately pubs and clubs
will be smoke free zones. This is an initiative by the government to create
an environment that is conducive to people‟s health.

Without a supportive environment people won‟t be able to change. They
need to be able to feel encouraged and supported. This is very important
when it comes to people quitting smoking. This is a very important
component of the Ottawa Charter.

Strengthening Community Action

“Health promotion works through concrete and effective community action
in setting priorities, making decisions, planning strategies and
implementing them to achieve better health. At the heart of this process is
the empowerment of communities, their ownership and control of their own
destinies and endeavours”.

This action area of the Ottawa Charter is about changing the way people
think about health. In the past people have been unsupportive about health
problems. This action area aims at changing this to a supportive way of
thinking. It also encourages the community to work together to develop
policies and to solve these problems.

Our local communities attitude towards smoking is beginning to change.
People no longer find it acceptable for a person to smoke indoors or for a
parent to smoke in the car with their child. People are beginning to expect
places to be smoke free which is very important to be able to change our
whole society‟s view on smoking from tolerating it to disagreeing and even
making a stand for having a smoke free environment.
Reorientating Health Services

“The responsibility for health promotion in health services is shared among
individuals, community groups, health professionals, health care
institutions and governments. They must work together towards a health
care system that contributes to the pursuit of health. The role of the health
sector must move increasingly in a health promotion direction, beyond its
responsibility for providing clinical and curative services”. [15]

This action area focuses on prevention as opposed to cure. It is changing
the focus of health from that of being reactive to proactive. This involves
going out into the community to prevent health problems before they

It is possible to prevent lung cancer by not exposing yourself to asbestos
and other carcinogenic chemicals and not smoking. The government has
many initiatives that aim at reducing the number of people that smoke.

Most of these initiatives use „scare‟ tactics. These are visual
advertisements on television or on cigarette packets that show you what
you are doing to your lungs or what you could be doing to your children.
These include the „Every-cigarette-is-doing-you-damage‟ advertisements,
„car and home smoke free zone‟ and „smoking – what is it costing you?‟ All
of these advertisements aim at preventing lung cancer by scaring people
into not smoking by the graphic images.

There are other government initiatives such as the „Quit Week‟ and „World
No Tobacco Day.‟ The quit line and website are probably the most well
known campaigns. These aim at giving people support through the time
when they are quitting smoking. These campaigns are all preventative
based measures that will hopefully prevent people from smoking and
therefore prevent lung cancer.

Although it is imperative to have curative services it is just as important to
have services and campaigns that prevent lung cancer. This is what this
action area of the Ottawa Charter aims to do.

Building Healthy Public Policy

“Health promotion policy combines diverse but complementary approaches
including legislation, fiscal measures, taxation and organisational change.
It is coordinated action that leads to health, income and social policies that
foster greater equity. Joint action contributes to ensuring safer and
healthier goods and services, healthier public services and cleaner, more
enjoyable environments”. [15]
The purpose of this action area is to make laws and policies so that
making wise, healthy choices are made easy. Thus creating a healthier

There are laws and policies in place in our community to limit the number
of people who smoke, the people who are exposed to cigarette smoke and
the influence that tobacco companies can have on people.

Anyone who wants to purchase cigarettes must be over eighteen years of
age. This limits the amount of people who smoke under the age of
eighteen because of the difficulty of buying cigarettes.

Every packet of cigarettes that is sold must have a warning and a picture
about what smoking can do to your health. This may discourage people
from smoking, as the pictures are very graphic.

Cigarette companies are no longer allowed to advertise their product in
any magazines, newspapers or on television. They are also not allowed to
sponsor any form of event. This limits the amount of people that are
exposed to the influence of advertising.

There are laws in place that limit where people are and aren‟t allowed to
smoke. For example in the near future people will not be allowed to smoke
in restaurants, public places, beaches, pubs and clubs. This not only
discourages people from smoking by not allowing them to smoke in so
many places but it limits the amount of ETS (environmental tobacco
smoke) that people will inhale.

This is possibly the most influential action area as it involves government-
approved laws that encourage a healthy way of living.

Conclusion of the Ottawa Charter

All of the action areas of the Ottawa Charter interact with each other to
promote a healthy way of living.

In reference to lung cancer, the first action area of the Ottawa Charter aims
at teaching people assertiveness – to be able to say no to smoking,
awareness about passive smoking – to be able to avoid it, and personal
knowledge – to be able to ultimately make up your own mind about
smoking. The second action area aims at creating an environment around
a person that makes it easy to make healthy choices in regards to smoking
and passive smoking. The third action area aims at changing the
mainstream view that smoking is acceptable to people eventually thinking
that it is unacceptable. The fourth action area endeavours to change the
focus of lung cancer from cure to prevention. The fifth and arguably most
important action area introduces legislation and public policies to create a
smoke-free and ultimately lung cancer-free society.

In conclusion, all of the action areas of the Ottawa Charter are imperative
to lowering the incidence of lung cancer. All the action areas work together
to help create a healthier society.

[1]PDHPE application and enquiry HSC course
ung _cancer
[15]Extract from Ottawa Charter, 1986