more_vertIn Europe and the USA, 700 000 people die after out-of-hospital cardiac arrest and unsuccessful cardiopulmonary resuscitation (CPR) every year,1 about 2000 deaths per day. These estimates apply to many other parts of the world. This cause of death is probably the third most common cause of death in developed countries, after all cancers combined and other cardiovascular causes.1 When professional emergency medical services arrive after cardiac arrest—which can be after 8–12 min or more—the brain has already started to die.
Preference: Administration and Health Services
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Sky-high Indigenous imprisonment rates a health disaster
Imprisonment is rarely good for health, particularly if you are an Indigenous Australian.
But, tragically, Indigenous people are far more likely to be locked up than other Australians, exacerbating health problems and sending many into a downward spiral of illness and premature death.
The figures are stark.
In 1991, the Royal Commission into Aboriginal Deaths in Custody identified extraordinary rates of incarceration among Indigenous Australians compared with the rest of the community, and established a link with poor general and mental health.
But, despite the Royal Commission’s recommendations, the situation has got significantly worse.
Among Aboriginal and Torres Strait Islanders, the adult imprisonment rate soared 57 per cent between 2000 and 2013, while juvenile detention rates increased sharply between 2000-01 and 2007-08, and have fluctuated ever since at around 24 times the rate for non-Indigenous youth.
Currently, almost a third of all prisoners are Aboriginal, including 48 per cent of juveniles held in custody.
Not only that, but the rate of reoffending is astronomical. In fact, repeat offending and re-incarceration is a large contributor to this high rate of imprisonment.
Shocking though these statistics are, they do not begin to describe the suffering and distress experienced by incarcerated Indigenous people, their families and communities.
Mental illness and mental health problems, including alcohol and drug abuse, contribute significantly to their rates of imprisonment and recidivism.
Being incarcerated, in turn, exacerbates existing conditions in prisoners. And, without appropriate and effective treatment within prison, mental illness and mental health issues are a major factor in poor outcomes for people released from prison, including suicide, death from overdose or injury and reoffending.
Social disadvantage and a history of upheaval culminating in trauma and grief clearly contribute to the high level of imprisonment among Indigenous Australians.
Many studies published since 2000 have highlighted that Aboriginal people already have a higher prevalence of significant psychological distress when compared to the non-Aboriginal population, disrupting social and emotional wellbeing and causing post-traumatic stress disorder, depression and substance abuse.
Alcohol is well-known as a common precursor to offending among Indigenous Australians, with indications that it could be a factor in up to 90 per cent of all Indigenous contacts with the justice system.
Once incarcerated, Aboriginal prisoners are at greater risk of developing or exacerbating a mental illness. Ninety-three per cent of Aboriginal women in jail, and 81 per cent of men, have some form of mental illness. Altogether, 30 per cent of Aboriginal women and 20 per cent of Aboriginal men in jail have attempted suicide, and 33 per cent of Aboriginal women and 12 per cent of Aboriginal men suffer from post-traumatic stress disorder.
It is apparent that there is a complete lack of appropriate services to meet complex social, cultural and health needs.
A clearer understanding of some of the drivers of incarceration of Aboriginal and Torres Strait Islander men and women is needed, as are better interventions through culturally appropriate health and disability services before entering custody, during imprisonment, at the time of release and post-release.
There are several things that can and should be done to end this vicious cycle of illness, abuse and incarceration for Indigenous people, including making it much easier for Indigenous offenders to get into diversion programs for alcohol and drug-related offences; establishing Indigenous-specific diversion programs linked to Aboriginal community controlled services; improving the level of health services for Indigenous prisoners; comprehensive health screening for those entering prison, and channelling them into appropriate treatment; and research and develop performance indicators to guide effective health services for Indigenous offenders.
These matters will be considered in the AMA’s Indigenous Health Report Card, which will be released later this year.
Sickest, smallest to be hit hardest by Commonwealth cuts
The Federal Government has been warned that more people are likely to die because of an increasing shortfall of thousands of doctors, nurses and other health professionals in public hospitals as a result of Commonwealth cutbacks.
AMA President Associate Professor Brian Owler said the Abbott Government’s decision to reduce public hospital by $57 billion over 10 years would have a devastating effect on the State and Territory health systems.
“The AMA has warned of a perfect storm if funding is not increased,” A/Professor Owler said. “We already see hospitals struggling to achieve performance targets. We know that overcrowding, we know that delays in getting into a bed from the emergency department, is not just a matter of the headlines, it is matter of increased morbidity. People have more complications or are more likely to die if they spend more and more time in an emergency department.”
The AMA National Conference was told that in Queensland alone, the Federal Government’s decision to slash growth in public hospital funding from 2017 will rip $11.8 billion out of the State health system over 10 years, resulting in 1503 fewer doctors and 5319 fewer nurses being employed in the time.
A/Professor Owler said the outlook for the smaller states and territories, which had limited revenue-raising capacity, was particularly worrying.
“I really fear for those states, because we know that their economies are quite small. They don’t have the ability to make up the shortfall in revenue, and those states are going to be really badly affected,” he said.
Queensland Health Minister Cameron Dick told the AMA National Conference that the Commonwealth was shoving more of the burden of public hospital funding on to the states.
Mr Dick released modelling by his Department showing that the Commonwealth’s share of national efficient public hospital expenditure would peak at 35.5 per cent in 2016-17 before rapidly falling away to just 32.1 per cent by 2024-25 – virtually 10 percentage points below the level committed to in the 2011 National Health Reform Agreement.
“There will be greater pressure on the hospital system as a result,” the Queensland Minister said. “People will have to wait longer for surgery, people will have to wait longer for patient appointments. We will not be able to deliver the services we need. As the population gets older and costly medical technology increases, there will be a gap.”
AMA Tasmania President Dr Tim Greenaway described to the AMA National Conference how the Commonwealth funding cut would hit his State particularly hard.
Tasmania has the nation’s oldest, fattest, poorest and – by many measures – least healthy population, and Dr Greenaway warned the Federal Government’s policy would only make the situation worse.
Despite having greater health needs than most other states and territories, Tasmania’s spending on health care ($1275 per capita) is below the national average ($1735 per capita), and Dr Greenaway said the Commonwealth’s funding cuts would only “lock in” the State’s inadequate investment in health, “which will inevitably increase health disparity”.
The states and territories are furious the Federal Government has walked away from its commitments under the National Health Reform Agreement, and the issue is set to be near the top of the agenda when Prime Minister Tony Abbott meets with his State and Territory counterparts to discuss reform of the Federation at a leader’s retreat in July.
A/Professor Owler said the Federal Government’s decision was indefensible.
“It’s up to the Commonwealth to live up to its responsibility to make sure that all Australia’s get access to the services they deserve,” he said, adding that the squeeze on hospitals would also have a significant effect on doctor and nurse training.
A video of the Quality public hospital services: funding capacity for performance policy session can be viewed at: media/ama-national-conference-30-may-2015-session-1
Adrian Rollins
Access to health services by Australians with disability 2012
In 2012, 17% of people with disability who needed to see a GP delayed or did not go because of the cost; 20% who needed to see a medical specialist did not go mainly due to the cost; and 67% who needed to see a dentist delayed seeing or did not go because of the cost. Compared with people with disability living in Major cities, people with disability living in Outer regional and Remote areas had lower use rates of services provided by GPs, medical specialists and dentists as well as coordinated care provided by different types of health professionals. They were more likely to visit a hospital emergency department for health issues that could potentially be dealt with by non-hospital services, and to face barriers to accessing health services.
Incentives hold out promise of better after hours care
The Federal Government has promised patients will find it simpler and easier to see a GP at night or on weekends following the reinstatement of incentives for medical practices to provide after hours services.
In a move strongly supported by the AMA, Health Minister Sussan Ley has announced that almost $99 million will be provided next financial year to pay practices that operate extended hours or make arrangements for their patients to receive after hours care.
Ms Ley said access to after hours GP care was an issue that was raised consistently during her consultations with the medical profession and the community since becoming Minister, and the incentive would give “positive support” to practices that ensured their patients had access to after hours care.
The reinstatement of the incentive was a key recommendation of the review of after hours primary health services led by Professor Claire Jackson, and followed widespread dissatisfaction with the arrangement under the previous Labor Government to give Medicare Locals responsibility for co-ordinating and funding after hours services.
AMA President Associate Professor Brian Owler applauded the Minister for moving so swiftly to reinstate the Practice Incentives Program After Hours Incentive.
A/Professor Owler said the AMA had been calling for the return of the PIP funding “for some time” because of the benefit it would provide to both patients and practices.
“The new PIP payment structure will encourage and support general practices to provide after hours coverage for their patients, which will in turn ensure continuity of care,” the AMA President said. “Individual practices will now have greater control over after hours services for their patients, [and] patients will benefit.”
To pay for the reinstatement of the PIP incentive, the Government has scrapped the After Hours GP Helpline and redirected funds freed up by the abandonment of the Medicare Locals network.
Though some complained that the Helpline has provided a vital service, the Jackson review found there was little evidence it had reduced the pressure on rural doctors to attend after hours call-outs or improved continuity of care. It recommended that the service be scrapped and the funds instead directed into GP incentives.
While details of eligibility requirements for the incentives are yet to be released, the scheme –which commences on 1 July – will offer five payment levels depending on the degree of service provided.
They range from the very basic, level 1 service involving “formal” arrangements for patients to seek after hours care at another provider, through to a full service model where a practice has staff rostered on around the clock, seven days a week.
The incentive would rise from $1 for each Standardised Whole Patient Equivalent (an age-weighted measure based on GP and other non-referred consultation items in the MBS) at a level 1 practice, rising to $11 per SWPE at the top end.
The Minister said all practices would be required to inform patients of their after hours arrangements, and to ensure that correct details were provided in the National Health Service Directory.
“Under these new arrangements, patients will be able to easily find out what after-hours services are available, including services provided by arrangement outside of the patient’s usual general practice,” Ms Ley said.
The reintroduction of the after hours PIP has coincided with the Federal Government’s move to scrap Medicare Locals and replace them with larger Primary Health Networks.
Importantly, the Government has specified a different role for PHNs regarding the provision of after hours services than that fulfilled by the Medicare Locals.
Under the new arrangement, PHNs will be required to work with “key local stakeholders” to plan, co-ordinate and support after hours health services, with a particular focus on “addressing gaps in after hours service provision, ‘at risk’ populations and improved service integration”.
A/Professor Owler said the change in focus and function was welcome.
“The Government has listened and responded to AMA concerns about giving responsibility for after hours funding to Medicare Locals, which has proven to largely be a failure and simply increased red tape for practices,” the AMA President said. “While the new Primary Health Networks will still have a role to play in ensuring community access to after hours health services, their focus will be on gaps in service delivery.”
Adrian Rollins
Govt wants kids to have cut-price health checks
The Federal Government wants children to have cut-price health checks after confirming it would rip almost $145 million out of general practice by abolishing a Medicare program that last year provided comprehensive pre-school health assessments for 154,000 children.
But Health Minister Sussan Ley said parents would still be able to get their GP to conduct a similar Medicare-funded health check of their child, though at a fraction of the cost to the taxpayer.
The Minister was forced to make the clarification after an announcement in the Federal Budget that $144.6 million would be taken out of general practice over the next four years by “removing the current duplication” Medicare-funded health checks and child health assessments provided by the states and territories.
AMA President Associate Professor Brian Owler voiced concern about the cut, saying it was “very unclear” whether or not there was duplication occurring.
The measure was also heavily criticised by health groups angered by what appeared to be a decision to axe comprehensive health checks for children aged three to five years, introduced by the former Labor Government in 2008.
But Ms Ley rushed to assure parents that they could still get Medicare-funded health checks for their children.
“Parents needing to access the pre-school health check for their child in order to access income support will still be able to do so through a GP or the various state-based nurse infant and children checks, as is currently the case,” the Minister said. “The only change in the Budget is to the Medicare items GPs can bill taxpayers and patients for undertaking the check.”
The Government has moved to scrap Labor’s “Healthy Kids Check”, which costs Medicare $268.80 per visit, and instead allow GPs to bill for the check as a standard GP item costing $105.55 for an equivalent amount of time.
“Instead of GPs billing a special Medicare item worth hundreds of dollars per visit, they will instead be able to deliver the pre-school health check for three- and four-year-olds through a standard GP item worth about half that,” Ms Ley said.
The Government said an increase in the number of people using the Healthy Kids Check in recent years had sent the cost spiralling.
It reported that the number of assessments had jumped from 40,031 in 2008-09 to 153,725 last financial year, driving the annual cost from $1.8 million to $20 million.
While lamenting the cost of the program, Ms Ley simultaneously criticised it for not being comprehensive enough.
“Currently, only half of Australia’s 300,000-plus four-year-olds have accessed a pre-school health check at the more expensive billing rates,” the Minister said, adding there was no evidence show Labor’s program provided health checks superior to standard GP and state infant check services.
But a study published in the Medical Journal of Australia last year did not support this conclusion.
It found the program was effective in detecting problems with speech, toileting, hearing, vision and behaviour in about 20 per cent of children, and directly led to changes in the clinical management of between 3 and 11 per cent of such children.
The study’s authors said their results suggested “GPs are identifying important child health concerns during the Healthy Kids Checks, using appropriate clinical judgement for the management of some conditions, and referring when concerned”.
They added that GPs were also using the checks as an opportunity to identify other health problems.
The authors admitted to having no knowledge of the cost-effectiveness of the program, “although, given that its timing coincides with vaccination at four years of age, the incremental cost is likely small”.
It followed a study published in the MJA in 2010 which found that although the evidence behind the Healthy Kids Check at that stage was “not compelling”, it had the potential to play an important role in monitoring child development by filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services.
Adrian Rollins
Smoking cessation advice and non-pharmacological support in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers
Quitting smoking reduces the risk of smoking-related death, with greater benefits from quitting at a younger age.1 Receiving brief advice to quit from health professionals and more intensive support from specialist clinics and courses, stop-smoking medicines, telephone quitlines, websites and printed materials have been shown to increase successful quitting.2–8 In Australia, just over half of smokers have been recently advised to quit, and a similar proportion of those who have tried to quit have used stop-smoking medicines.9,10 Fewer smokers are referred to or use other cessation support services.9–11
In 2012–2013, Aboriginal and Torres Strait Islander adults had 2.5 times the smoking prevalence of other Australian adults, and those who had ever smoked were less likely to have successfully quit (37% v 63%).12 There is a long history of widespread training in how to give brief advice for health professionals working with Aboriginal and Torres Strait Islander peoples.13 In recent years, the national Tackling Indigenous Smoking program has increased funding to support this training, enhancement of the telephone Quitline service to be more culturally appropriate, and other local cessation support activities.14
Here, we describe recall among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers of having received advice to quit smoking and referral to non-pharmacological cessation support from health professionals, and examine the association of advice and referrals with making a quit attempt. We examine the use of stop-smoking medicines elsewhere in this supplement.15
Methods
The Talking About The Smokes (TATS) project surveyed 1643 Aboriginal and Torres Strait Islander smokers and 78 recent ex-smokers (who had quit ≤ 12 months before), using a quota sampling design based on the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. It has been described in detail elsewhere.16,17 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or recent ex-smokers and 25 non-smokers, with equal numbers of women and men, and those aged 18–34 and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged under 18 years, not usual residents of the area, staff of the ACCHS or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.
Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. A single survey of health service activities was also completed at each site. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.16
We asked all smokers and recent ex-smokers whether they had seen a health professional in the past year and, if so, whether they had been asked if they smoke and, if so, whether they had been encouraged to quit. We asked those who had been encouraged to quit about pamphlets or referrals to the Quitline, quit-smoking websites, or quit courses or clinics they had received. We also asked all smokers and recent ex-smokers whether they had sought out these services themselves, and about quit attempts and sociodemographic factors. At each site, we asked questions about tobacco control funding and staff positions to determine if the health service had resources dedicated to tobacco control. The questions reported here are described in detail in Appendix 1.
The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.18 TATS project results were compared with those of 1412 daily smokers newly recruited to Waves 5–8 (2006–2011) of the Australian ITC Project. The ITC Project survey was conducted by random digit telephone dialling. We only used data from the newly recruited participants as questions for recontacted participants referred to advice received since the previous survey rather than in the past year. Slightly different definitions of smokers between the TATS project and ITC Project surveys meant that only daily and weekly smoker categories were directly comparable. We concentrated our comparisons on daily smokers. We have also concentrated our other descriptions of recall of advice and associations between variables within the TATS sample on daily smokers.
The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.
Statistical analyses
We calculated the percentages and frequencies of responses to the TATS project questions, but did not include confidence intervals for these as it is not considered statistically acceptable to estimate sampling error in non-probabilistic samples. We compared results for daily smokers with those in the Australian ITC Project surveys, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.
Within the TATS project sample, we assessed the association between variables using simple logistic regression, with confidence intervals adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands.19 P values were calculated using adjusted Wald tests.
Reported percentages and frequencies exclude those refusing to answer or answering “don’t know”, leading to minor variations in denominators between questions. Less than 2% of daily smokers answered “don’t know” or refused to answer each of the questions analysed here.
Results
Three-quarters of Aboriginal and Torres Strait Islander daily smokers (76%) reported having seen a health professional in the past year (Box 1). Of these, 93% said they were asked if they smoked, and 75% also reported being advised to quit. These proportions are higher than those among Australian daily smokers in the ITC Project.
Within the TATS project sample, Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional had twice the odds of having made a quit attempt in the past year, compared with those who did not recall being advised to quit (Box 2).
The proportion of Aboriginal and Torres Strait Islander daily smokers who had been advised to quit increased with age and was higher among women, those with post-school qualifications and those whose local health service had dedicated tobacco control resources; the proportion was lower among the unemployed (Box 3). There was more sociodemographic variation in having seen a health professional than in recalling being advised to quit (Appendix 2).
Among all Aboriginal and Torres Strait Islander smokers and ex-smokers who were advised to quit, 49% were given a pamphlet or brochure on how to quit, and lower proportions were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%) (Box 4). Most of those who received pamphlets said they read them (70%, 321/457), but lower proportions reported following up on other referrals. Daily smokers who were referred to each resource were non-significantly more likely to have made a quit attempt in the past year than those who had been advised to quit but not referred (Box 2). We also found that 13% of smokers and recent ex-smokers (215/1696) had sought out quit information or services themselves, and that 62% (1047/1692) had been encouraged by family or friends to quit or to maintain a quit attempt.
A higher proportion of the Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional in the past year had been given a pamphlet, compared with other Australian daily smokers in the ITC Project (50% [390/778] v 29.6% [95% CI, 25.4%–34.3%]).
Discussion
Daily smokers in our Aboriginal and Torres Strait Islander sample were more likely than those in the broader Australian ITC Project sample to recall having been advised to quit by a health professional in the past year. This was in part due to being more likely to have been seen by a health professional, but mainly due to a greater proportion of those seen being advised to quit.
Strengths and limitations
The main strength of this study is its large, nationally representative sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. However, the sample was not random and there were some sociodemographic differences compared with a random sample of the population.16
Our survey was conducted face to face, whereas the comparison Australian ITC Project surveys were conducted by telephone, potentially leading to differential social desirability bias. Further, some ITC Project surveys were conducted much earlier than the TATS project survey, and although many questions were identical on both surveys, the order and structure of the comparison ITC Project questionnaire was different. While we are confident that the large difference in recall of health professional advice between the TATS project and ITC Project samples is real, we have not described the differences in referral to cessation support as, except for the question about pamphlets, the questions were not directly comparable.
The main limitation of our study is that partnering with ACCHSs to recruit participants may have led to a selection bias towards people with closer connections to the health services, inflating the percentage who recalled being seen by a health professional. However, this percentage was similar to that reported in the 2004–2005 National Aboriginal and Torres Strait Islander Health Survey.16 We also report a higher prevalence of having received advice among only those who had seen a health professional, which would be less affected by this bias. Our results are also based on patient recall, not clinical records. Australian general practice research has found that clinical records poorly record health advice and poorly agree with patient recall of referrals to other cessation services.10 Some patients will have misremembered or forgotten advice and referrals they received, but we would expect that advice and referrals that were useful for quitting would be more likely to be remembered.
Comparisons with other studies
The proportion of smokers who had seen a health professional and recalled being asked if they smoke was similar to that among a sample of pregnant Aboriginal and Torres Strait Islander women who smoked, who were only slightly more likely to be advised to quit (81% of pregnant smokers v 75% of daily smokers in our sample).20
SmokeCheck, a commonly used training program to increase health professionals’ skills in giving brief quit-smoking advice to Aboriginal and Torres Strait Islander patients, has been shown to improve participants’ confidence in regularly providing brief advice.21,22 The long history of such training programs, along with support for and promotion of brief interventions in ACCHSs, may have contributed to advice being given more often to Aboriginal and Torres Strait Islander smokers than other smokers.
We found that the likelihood of receiving advice to quit from health professionals increased with participant age, as in earlier Australian ITC Project research.9 Most of the focus of chronic disease prevention is on older patients, but there is an opportunity to increase the provision of advice about smoking to younger patients.
Our finding that a high proportion of Aboriginal and Torres Strait Islander daily smokers recalled receiving this advice is encouraging, as even brief advice from a doctor increases cessation, with minimal additional benefit from more extensive advice or follow-up.2 Provision of brief advice is achievable even in very busy primary care settings and, as we found, can reach most of the population. In both urban and remote settings, Aboriginal and Torres Strait Islander interviewees in qualitative research have emphasised that advice and support from health professionals was a significant factor in their quit attempts.23–25 Consistent with this, we found that recalling advice from a health professional to quit was associated with making a quit attempt. While it is possible that making an attempt may increase the likelihood of advice being recalled, or may have led to making a visit to a health professional, it seems reasonable to conclude that advice from health professionals is contributing to Aboriginal and Torres Strait Islander smokers’ motivation to try to quit.
The frequent use of pamphlets by Aboriginal and Torres Strait Islander smokers is positive but not likely to have much impact on cessation, as the additional effect of such printed material is only modest.6 In contrast, Cochrane reviews show a greater effect on cessation of telephone quitlines, more intensive individual counselling outside primary care, and quit groups.4,7,8 Currently, evidence for internet-based quit support is inconsistent but promising.5
A meta-analysis of two randomised controlled trials showed intensive cessation counselling programs for Aboriginal and Torres Strait Islander smokers were effective in increasing cessation.26 We found that most people who attended special cessation programs said they were specifically designed for Aboriginal and Torres Strait Islander peoples.
Quitlines can be a cost-effective element in cessation support, but there has been a perception of distrust and low usage of quitlines by Aboriginal and Torres Strait Islander people.13 In 2010, Aboriginal and Torres Strait Islander callers to the Quitline in South Australia received fewer calls back and were less likely to have successfully quit than non-Indigenous callers.27 Since then, the Tackling Indigenous Smoking program has funded activity to improve the appropriateness and accessibility of the Quitline.
These non-pharmacological cessation support options benefit smokers who use them, but we found that most do not, as has been found in other contexts.9–11 Indigenous and non-Indigenous Australian research has shown that many smokers see using cessation support as a sign of weakness and lack of willpower, which is a challenge in promoting these evidence-based services.24,28
1 Daily smokers’ recall of receiving advice to quit when seeing a health professional in the past year*
|
Australian ITC Project, % (95% CI)† |
TATS project, % (frequency)‡ |
||||||||||||||
|
|
|||||||||||||||
|
Seen a health professional |
68.1% (64.8%–71.1%) |
76% (1047) |
|||||||||||||
|
Of those seen |
|||||||||||||||
|
Asked if he/she smokes§ |
— |
93% (968) |
|||||||||||||
|
Advised to quit |
56.2% (52.3%–59.9%) |
75% (782) |
|||||||||||||
|
|
|||||||||||||||
|
ITC Project = International Tobacco Control Policy Evaluation Project. TATS = Talking About The Smokes. * Percentages and frequencies exclude refused responses and “don’t know” responses. † Results are for daily smokers (n = 1412) newly recruited to Waves 5–8 of the Australian ITC Project (2006–2011) and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results are for Aboriginal and Torres Strait Islander daily smokers (n = 1377) in the baseline sample of the TATS project (April 2012 – October 2013). § Not asked in the Australian ITC Project. |
|||||||||||||||
2 Aboriginal and Torres Strait Islander daily smokers who made a quit attempt in the past year, by recall of being advised to quit and referred to cessation support
|
Attempted to quit in the past year |
|||||||||||||||
|
% (frequency)* |
Odds ratio (95% CI)† |
P‡ |
|||||||||||||
|
|
|||||||||||||||
|
All daily smokers (n = 1354) |
|||||||||||||||
|
Advised to quit by a health professional in the past year |
< 0.001 |
||||||||||||||
|
No |
39% (223) |
1.0 |
|||||||||||||
|
Yes |
56% (433) |
2.00 (1.58–2.52) |
|||||||||||||
|
If advised to quit by a health professional in the past year (n = 777)§ |
|||||||||||||||
|
Given a pamphlet |
0.053 |
||||||||||||||
|
No |
52% (203) |
1.0 |
|||||||||||||
|
Yes |
60% (230) |
1.34 (1.00–1.79) |
|||||||||||||
|
Referred to telephone Quitline |
0.15 |
||||||||||||||
|
No |
55% (306) |
1.0 |
|||||||||||||
|
Yes |
60% (125) |
1.25 (0.92–1.68) |
|||||||||||||
|
Referred to quit-smoking website |
0.48 |
||||||||||||||
|
No |
55% (305) |
1.0 |
|||||||||||||
|
Yes |
58% (121) |
1.13 (0.80–1.6) |
|||||||||||||
|
Referred to quit course, group or clinic |
0.19 |
||||||||||||||
|
No |
55% (357) |
1.0 |
|||||||||||||
|
Yes |
61% (73) |
1.30 (0.88–1.92) |
|||||||||||||
|
|
|||||||||||||||
|
* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated using adjusted Wald tests. § Only participants who recalled being advised to quit by a health professional were asked about referral to cessation support resources. |
|||||||||||||||
3 Aboriginal and Torres Strait Islander daily smokers who recalled being advised to quit by a health professional in the past year, by sociodemographic factors (n = 1366)
|
Advised to quit by a health professional |
|||||||||||||||
|
Characteristic |
% (frequency)* |
Odds ratio (95% CI)† |
P‡ |
||||||||||||
|
|
|||||||||||||||
|
Total |
57% (782) |
||||||||||||||
|
Age (years) |
0.001 |
||||||||||||||
|
18–24 |
48% (136) |
1.0 |
|||||||||||||
|
25–34 |
55% (203) |
1.29 (0.93–1.79) |
|||||||||||||
|
35–44 |
58% (188) |
1.47 (1.01–2.16) |
|||||||||||||
|
45–54 |
62% (145) |
1.72 (1.15–2.57) |
|||||||||||||
|
≥ 55 |
71% (110) |
2.61 (1.67–4.06) |
|||||||||||||
|
Sex |
0.003 |
||||||||||||||
|
Male |
52% (342) |
1.0 |
|||||||||||||
|
Female |
62% (440) |
1.50 (1.15–1.95) |
|||||||||||||
|
Indigenous status |
0.74 |
||||||||||||||
|
Aboriginal |
57% (694) |
1.0 |
|||||||||||||
|
Torres Strait Islander or both |
59% (88) |
1.07 (0.73–1.56) |
|||||||||||||
|
Labour force status |
< 0.001 |
||||||||||||||
|
Unemployed |
48% (226) |
1.0 |
|||||||||||||
|
Not in labour force |
65% (273) |
2.00 (1.47–2.71) |
|||||||||||||
|
Employed |
59% (282) |
1.57 (1.20–2.05) |
|||||||||||||
|
Highest education attained |
0.007 |
||||||||||||||
|
Less than Year 12 |
54% (380) |
1.0 |
|||||||||||||
|
Finished Year 12 |
57% (206) |
1.17 (0.91–1.51) |
|||||||||||||
|
Post-school qualification |
66% (194) |
1.72 (1.23–2.41) |
|||||||||||||
|
Treated unfairly because Indigenous in past year |
0.72 |
||||||||||||||
|
No |
58% (342) |
1.0 |
|||||||||||||
|
Yes |
57% (423) |
0.96 (0.75–1.22) |
|||||||||||||
|
Remoteness |
0.33 |
||||||||||||||
|
Major cities |
54% (194) |
1.0 |
|||||||||||||
|
Inner and outer regional |
60% (430) |
1.25 (0.86–1.81) |
|||||||||||||
|
Remote and very remote |
54% (158) |
0.98 (0.64–1.52) |
|||||||||||||
|
Area-level disadvantage |
0.18 |
||||||||||||||
|
1st quintile (most disadvantaged) |
55% (285) |
1.0 |
|||||||||||||
|
2nd and 3rd quintiles |
61% (357) |
1.28 (0.94–1.74) |
|||||||||||||
|
4th and 5th quintiles |
54% (140) |
0.97 (0.68–1.38) |
|||||||||||||
|
Local health service has dedicated tobacco control resources |
0.05 |
||||||||||||||
|
No |
52% (207) |
1.0 |
|||||||||||||
|
Yes |
60% (575) |
1.38 (1.00–1.91) |
|||||||||||||
|
|
|||||||||||||||
|
* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated for the entire variable, using adjusted Wald tests. |
|||||||||||||||
4 Aboriginal and Torres Strait Islander smokers and recent ex-smokers who recalled receiving or being referred to cessation support resources when advised to quit by a health professional (n = 960)*
|
Pamphlet |
Quit-smoking website |
Telephone Quitline |
Quit course, group or clinic |
||||||||||||
|
|
|||||||||||||||
|
Received information or a referral |
49% (460) |
27% (252) |
28% (266) |
16% (149) |
|||||||||||
|
If so, read, used or attended it |
70% (321) |
22% (54) |
16% (43) |
44% (65) |
|||||||||||
|
If so, it was specifically for Aboriginal and Torres Strait Islander peoples |
52% (168) |
48% (26) |
44% (18) |
88% (56) |
|||||||||||
|
|
|||||||||||||||
|
* Data only include smokers and recent ex-smokers who recalled being advised by a health professional to quit. Percentages and frequencies exclude those answering “don’t know” or refusing to answer. |
|||||||||||||||
Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers
Television advertisements and warning labels on tobacco products are the most commonly cited sources of information on the dangers of smoking.1,2 There is good evidence that messages about the harms of smoking increase knowledge, worry about health risks, attempts to quit, and even quit success.3–7 These messages aim to either change pro-smoking attitudes and intentions or strengthen those that support quitting.8
Smoking is the leading cause of sickness and death among Aboriginal and Torres Strait Islander peoples.9 To tackle this, funding was established in 2009 for community-led programs that raise awareness, provide education and challenge norms about smoking.10 Australia also launched its first national Indigenous Anti-Smoking Campaign (“Break the Chain”) in March 2011.11 These targeted programs ran alongside the National Tobacco Campaign, state and territory campaigns, and other sources of information, such as news media. In addition, plain packaging of tobacco products, with new and larger warning labels, was mandated from 1 December 2012.12
Some experts doubt the effectiveness of mainstream messages in reducing smoking among Aboriginal and Torres Strait Islander peoples.13 While culturally relevant messages are preferred,14 mainstream media campaigns achieve high recall,15–17 including in remote areas.17,18 Here, we describe recall of anti-tobacco advertising and information (mainstream and targeted), pack warning labels and news stories among Aboriginal and Torres Strait Islander smokers, and assess the association of these messages with attitudes that support quitting.
Methods
Survey design and participants
The Talking About The Smokes (TATS) project surveyed 1643 current smokers from April 2012 to October 2013 (Wave 1, or baseline), and has been described in detail elsewhere.19,20 Briefly, we used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait (project sites), which were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers or recent quitters (ex-smokers who had quit ≤ 12 months previously), with even numbers of men and women, and people aged 18–34 and ≥ 35 years. The sample size was doubled in four large city sites and in the Torres Strait community. People were excluded if they did not identify as Aboriginal or Torres Strait Islander, were under 18 years of age, were not usual residents of the area, were staff of the ACCHS, were unable to complete the survey in English if there was no interpreter available, or if the quota for the relevant age–sex–smoking category had been filled. In each site, different locally determined methods were used to collect a representative, albeit non-random, sample.
Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, took 30–60 minutes to complete. A single survey of health service activities was also completed for each project site.
The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and by number of cigarettes smoked per day for current daily smokers. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.19
The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.
Questions on health information exposure
As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), survey questions were based on ITC Project survey questions and are presented in Appendix 1. How often respondents noticed warning labels (in the past month), anti-tobacco news stories (in the past 6 months) and anti-tobacco advertising or information (in the past 6 months) was assessed on a five-point scale ranging from “never” to “very often”, which was later collapsed to three categories (never, sometimes, often).
Smokers who said they had never noticed advertising or information (hereafter collectively referred to as advertising) in the past 6 months were not asked further related questions. Smokers who had noticed advertising were asked whether it was on: television, radio, the internet, outdoor billboards, newspapers or magazines, shops or stores, pamphlets, and posters in various locations (yes or no). Those who recalled noticing advertising in the past 6 months were also asked whether any had featured an Aboriginal or Torres Strait Islander person or artwork (“targeted advertising”) and, if so, whether any featured an Aboriginal or Torres Strait Islander person or artwork from the local community (“local advertising”). We combined these responses to create the variable “type of advertising”, which categorised smokers as having: never noticed any advertising, noticed mainstream (but no targeted) advertising, noticed some targeted (but no local) advertising, or noticed some local advertising.
Main outcome measures and covariates
There were four main outcomes: believing smoking is dangerous to others (“agree” or “strongly agree” that cigarette smoke is dangerous to both non-smokers and children), being very worried that smoking will damage the smoker’s own health in the future, agreeing that mainstream society disapproves of smoking, and wanting to quit. Additional analyses were conducted on forgoing cigarettes because of warning labels.
Covariates included daily or non-daily smoking status and key sociodemographic indicators (sex, age, identification as Aboriginal and/or Torres Strait Islander, labour force status, education, remoteness and area-level disadvantage). We also assessed for variation according to tobacco control activity that had occurred at the project site over the previous year (whether there were dedicated tobacco control resources, and the number of media used to communicate anti-tobacco advertising), which was determined in the project site survey.
We also assessed differences in warning label recall before and after plain packaging was mandated (1 December 2012), treating the 3-month phase-in period as “before”.
Statistical analyses
Logistic regression was used to assess: (i) variation in health information recall (often v sometimes or never) by daily smoking status, sociodemographic variables, and tobacco control activity at the project site; (ii) the association between health information recall and the four main outcome measures; and (iii) variation in warning label recall and outcomes before and after plain packaging was mandated. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, identifying the 35 project sites as clusters and the quotas (based on age, sex and smoking status) as strata.21
Data for health information recall were excluded for less than 2% of participants due to missing or refused responses, and for less than 2% due to “don’t know” responses. Questions about recall of warning labels were not asked of those who had not smoked in the past month (n = 44), nor those surveyed at the first project site (n = 26), after which questions were modified. These participants were therefore excluded from logistic regression analyses, which controlled for recall of each other type of health information, survey month (collapsed into 2-month blocks), daily smoking status and other sociodemographic covariates. Regression analyses for wanting to quit excluded a further 4.8% of smokers who responded “don’t know” to this question.
Results
Recall of health information
Of smokers who were asked about warning labels, 65% (1015/1557) said they had often noticed warning labels in the past month (Box 1). This was higher than the proportion of all smokers who recalled often noticing anti-tobacco advertising (45%; 730/1606) or news stories (24%; 386/1601) in the past 6 months.
Frequent recall of health information was similar for daily and non-daily smokers (Appendix 2). Fewer men than women reported often noticing warning labels (odds ratio [OR], 0.68; 95% CI, 0.51–0.90) and news stories (OR, 0.71; 95% CI, 0.51–1.00). While smokers from remote areas were less likely than those in major cities to recall often noticing advertising (OR, 0.56; 95% CI, 0.37–0.84), they were more likely to recall often noticing news stories (OR, 1.81; 95% CI, 1.18–2.79) and did not differ for recall of warning labels. Being from an area where the health service used a greater range of advertising media was associated with noticing it more often, with ORs increasing from 2.02 (95% CI, 1.15–3.57) for 5–8 media to 3.17 (95% CI, 1.84–5.46) for 9–12 media, compared with areas that used four or fewer media.
Associations with attitudes and wanting to quit
Recall of warning labels, advertising and news stories was positively associated with being very worried about future health and wanting to quit (Box 2). Only advertising recall was positively associated with believing society disapproves of smoking. For each outcome, the magnitude of ORs increased for those who recalled more targeted and local advertising, although this association was only significant for believing cigarette smoke is dangerous to others and wanting to quit.
Outcomes for warning labels before and after plain packaging
Compared with smokers surveyed in the period before plain packaging, those surveyed after its introduction were similarly likely to recall noticing warning labels but had higher odds for believing the labels made them more likely to quit (OR, 1.37; 95% CI 1.02–1.82) (Appendix 3). Smokers who had noticed warning labels in the past month were more likely to say these labels led them to forgo at least one cigarette after plain packaging compared with before it (OR, 1.54; 95% CI, 1.14–2.09). Further, those who said warning labels led them to forgo at least one cigarette were more likely to want to quit (OR, 3.73; 95% CI, 2.63–5.29) (data not shown).
Discussion
Advertising and information
We found high levels of recall of anti-tobacco advertising and information, particularly for television campaigns and local health promotion materials, which is likely to have been boosted by the community-led tobacco control activity that occurred over the survey period. However, even with this heightened activity, smokers from remote areas were less likely to say they often noticed advertising, consistent with trends for national mass media exposure.22 Recall of mass media advertising has been shown to increase with broadcast intensity,23–25 which is fundamental to achieving good reach among smokers of low socioeconomic status.6,25–27 Broadcast intensity is also important for influencing quitting activity and success.5,6,22,25,28,29
It is notable that targeted and local advertising was associated with higher levels of motivation to quit, a novel finding as far as we are aware. In part, targeted campaigns may be more memorable purely because of the interest in their targeted or local nature,30 which could be expected to weaken the observed relationship with wanting to quit. On the contrary, our results show the association increased in magnitude for recall of more targeted and local information, which suggests it is more potent than mainstream advertising. This finding is supported by analyses presented elsewhere in this supplement.31 While it is possible that the observed relationship could be due to higher exposure to all types of advertising, it remained significant irrespective of how often advertising was noticed.
Aboriginal and Torres Strait Islander peoples perceive targeted messages to be more relevant and effective,14,15,30 which may affect the influence of these messages on relevant attitudes. Among Maori people in New Zealand, culturally relevant campaigns have been shown to prompt discussions about smoking32 — an indirect effect of advertising that increases interest in quitting.33 While there is clear justification for targeted messages, together with emerging evidence regarding their benefit, consideration must also be given to whether this strategy is an effective use of scarce resources.34
Elsewhere, attitudes and intentions have been found to be most strongly influenced by advertising that evokes an emotional response, such as graphic or story-based messages.6,25,35 Such messages are rated highly by Aboriginal and Torres Strait Islander people and non-Indigenous Australians alike,14 and may also be an effective way to reduce disparities in quitting.36 How to best balance mainstream and targeted (including locally led) advertising will be an important area for future research.
Warning labels
We found that forgoing cigarettes was strongly associated with wanting to quit, as has been found in other settings,37,38 and that smokers were more likely to forgo cigarettes in the period after plain packaging was mandated than before. Although our before and after samples were not in any way random, the evidence is supportive of health warnings and plain packaging playing a role in maintaining concern about smoking. This is one of the aims of Australia’s plain packaging legislation, which increased the size of graphic warning labels, stripped all branding and regulated a drab brown pack colour.12
There is recent evidence that plain packaging increases the salience and effectiveness of health warnings.39–41 Our findings confirm these findings in a minority population with a high smoking prevalence. Further, our finding that warning label recall was not socially patterned adds to scarce evidence on the socioeconomic impacts of graphic pack warning labels, which has been identified as an international priority for tobacco control research.6,42
News stories
Frequent recall of news stories was related to higher levels of worry about health and interest in quitting, which supports previous findings that news items can complement paid sources of communication.6,43 We found no evidence of a social gradient in recall of news stories; in fact, they were more likely to be noticed often by smokers from remote areas. Online platforms to share and discuss news could play an important role here, and have been used effectively for Aboriginal tobacco control news and advocacy efforts.44 Local stories and those about leaders and other role models may be particularly influential.45,46
Strengths and limitations
This article draws on data from a broadly representative national sample of Aboriginal and Torres Strait Islander smokers. The size of the sample has enabled us to consider subgroup analyses based on socioeconomic indicators and other participant characteristics, including remoteness of residence. The frequency at which health promotional materials were recalled is likely to have been inflated by biased recruitment of project sites that prioritised tobacco control and of participants who were more connected to the health service. Although this means we cannot generalise results about how often different types of advertising and information were recalled, it does not compromise the findings on whether more frequent recall is associated with relevant attitudes and intentions.
The main limitation of our study is its reliance on self-report of awareness. It does not incorporate more objective media market data, as these would not capture some of the local activity and would therefore have been a limited source of information beyond the main media markets. Awareness can be affected by opportunity for exposure, the potency of the material, and the openness of the individual to the message. While it is impossible to separate these entirely, it is possible to infer likely relative contributions. For example, warning labels on packs are roughly equally available (albeit affected by levels of consumption) and are of largely fixed (standardised) potency. Thus, differences in recall and reactions can be largely attributed to the openness of the individual to the label’s message. When assessing associations with attitudes or intentions, we adjusted for noticing other types of health information (to control for variability due to openness) and for socioeconomic indicators (to control for variability due to opportunity for exposure), with the rationale that associations independent of these influences were a better assessment of potency. However, campaign effects are difficult to disentangle from other tobacco control efforts and contextual factors,3 particularly when using cross-sectional data. As such, a multivariable model that considers these factors has been reported in detail elsewhere for the outcome of wanting to quit.31
Finally, we report adjusted analyses, which necessarily exclude a small proportion of smokers who declined to answer questions, answered “don’t know”, had not smoked in the past month or were surveyed at the first project site. While it is possible that the excluded participants differ from those who were included, the same pattern of results was observed for unadjusted associations (where there were fewer exclusions) and where outcomes with a high percentage of “don’t know” responses (eg, wanting to quit) were repeated with “don’t know” recoded as “no”.
With these limitations in mind, we found a clear link between more frequent recall of health information and attitudes that support quitting, including wanting to quit. Further research is required to assess whether more targeted information is better able to tap into relevant beliefs and subsequently increase quitting.
1 Exposure to health information in a national sample of Aboriginal and Torres Strait Islander smokers*
|
Health information exposure variables |
% (frequency)† |
||||||||||||||
|
|
|||||||||||||||
|
Warning labels (in past month) |
|||||||||||||||
|
How often have you noticed the warning labels on packs your smokes are sold in? |
|||||||||||||||
|
Never |
11% (164) |
||||||||||||||
|
Almost never or sometimes |
24% (378) |
||||||||||||||
|
Often or very often |
65% (1015) |
||||||||||||||
|
Have the warning labels stopped you from having a smoke when about to? |
|||||||||||||||
|
Never noticed warning labels |
10% (164) |
||||||||||||||
|
Noticed warning labels but never stopped |
55% (887) |
||||||||||||||
|
Noticed warning labels and stopped at least once |
34% (550) |
||||||||||||||
|
News stories (in past 6 months) |
|||||||||||||||
|
How often have you seen or heard a news story about smoking or quitting? |
|||||||||||||||
|
Never |
30% (477) |
||||||||||||||
|
Almost never or sometimes |
46% (738) |
||||||||||||||
|
Often or very often |
24% (386) |
||||||||||||||
|
Advertising and information (in past 6 months) |
|||||||||||||||
|
How often have you noticed anti-tobacco advertising or information? |
|||||||||||||||
|
Never |
15% (241) |
||||||||||||||
|
Almost never or sometimes |
40% (635) |
||||||||||||||
|
Often or very often |
45% (730) |
||||||||||||||
|
Noticed any targeted advertising |
|||||||||||||||
|
Yes |
48% (783) |
||||||||||||||
|
No or never noticed advertising |
46% (745) |
||||||||||||||
|
Don’t know |
6% (96) |
||||||||||||||
|
Noticed any local advertising |
|||||||||||||||
|
Yes |
16% (258) |
||||||||||||||
|
No or never noticed mainstream or targeted advertising |
74% (1195) |
||||||||||||||
|
Don’t know |
11% (171) |
||||||||||||||
|
Did you notice advertising or information:‡ |
|||||||||||||||
|
On television |
82% (1327) |
||||||||||||||
|
On the radio |
43% (690) |
||||||||||||||
|
On the internet, including social media sites |
25% (390) |
||||||||||||||
|
On outdoor billboards |
45% (706) |
||||||||||||||
|
In newspapers or magazines |
47% (751) |
||||||||||||||
|
On shop windows or in shops where tobacco is sold (at point of sale) |
43% (679) |
||||||||||||||
|
In leaflets or pamphlets |
55% (877) |
||||||||||||||
|
Posters or displays at local health service |
74% (1186) |
||||||||||||||
|
Posters or displays at other Aboriginal or Torres Strait Islander organisation |
67% (1051) |
||||||||||||||
|
Posters or displays at local festival or community event |
59% (921) |
||||||||||||||
|
|
|||||||||||||||
|
* Results are from the Talking About The Smokes baseline sample of current smokers (n = 1643, or n = 1573 for questions regarding recall of warning labels). † Except where specified (for targeted and local advertising), percentages and frequencies exclude refused and “don’t know” responses, which accounts for differences in the total. ‡ Results are percentages of all smokers, including those who had never seen advertising or information in the past 6 months. |
|||||||||||||||
2 Association of health information exposure with attitudes in a national sample of Aboriginal and Torres Strait Islander smokers*
|
Believe smoking is dangerous to others |
Very worried smoking will |
Believe mainstream society |
Want to quit |
||||||||||||
|
% (frequency)† |
AOR (95% CI)‡ |
% (frequency)† |
AOR (95% CI)‡ |
% (frequency)† |
AOR (95% CI)‡ |
% (frequency)† |
AOR (95% CI)‡ |
||||||||
|
|
|||||||||||||||
|
Noticed warning labels (in past month) |
P < 0.001 |
P < 0.001 |
P = 0.45 |
P < 0.001 |
|||||||||||
|
Never |
77% (126) |
1.0 |
14% (22) |
1.0 |
58% (95) |
1.0 |
45% (71) |
1.0 |
|||||||
|
Sometimes |
86% (325) |
1.54 |
20% (75) |
1.41 |
55% (209) |
1.01 |
58% (204) |
1.31 |
|||||||
|
Often |
94% (953) |
3.56 |
44% (442) |
3.44 |
64% (650) |
1.21 |
78% (755) |
2.90 |
|||||||
|
Noticed news stories |
P = 0.12 |
P = 0.002 |
P = 0.12 |
P = 0.03 |
|||||||||||
|
Never |
90% (427) |
1.0 |
25% (118) |
1.0 |
64% (306) |
1.0 |
59% (271) |
1.0 |
|||||||
|
Sometimes |
91% (668) |
0.58 |
34% (250) |
1.56 |
59% (438) |
0.75 |
71% (491) |
1.40 |
|||||||
|
Often |
93% (359) |
0.67 |
49% (187) |
1.84 |
66% (254) |
0.73 |
81% (297) |
1.61 |
|||||||
|
Noticed advertising (in past 6 months) |
P = 0.004 |
P < 0.001 |
P < 0.001 |
P = 0.002 |
|||||||||||
|
Never |
82% (197) |
1.0 |
18% (42) |
1.0 |
58% (139) |
1.0 |
48% (112) |
1.0 |
|||||||
|
Sometimes |
91% (580) |
2.26 |
29% (179) |
1.10 |
56% (356) |
1.08 |
68% (403) |
1.57 |
|||||||
|
Often |
94% (684) |
2.78 |
47% (342) |
2.02 |
70% (510) |
2.07 |
79% (548) |
2.17 |
|||||||
|
Type of advertising |
P = 0.006 |
P = 0.25 |
P = 0.60 |
P < 0.001 |
|||||||||||
|
Never noticed any advertising |
82% (197) |
1.0 |
18% (42) |
1.0 |
58% (139) |
1.0 |
48% (112) |
1.0 |
|||||||
|
Noticed mainstream (but no targeted) advertising |
91% (522) |
1.94 |
32% (181) |
1.00 |
60% (345) |
1.00 |
65% (354) |
1.27 |
|||||||
|
Noticed some targeted (but no local) advertising |
93% (489) |
2.58 |
43% (224) |
1.15 |
66% (347) |
1.13 |
77% (388) |
1.99 |
|||||||
|
Noticed some local advertising |
95% (245) |
3.63 |
44% (112) |
1.34 |
66% (170) |
1.24 |
84% (202) |
2.88 |
|||||||
|
|
|||||||||||||||
|
AOR = adjusted odds ratio. * Results are based on the Talking About The Smokes project baseline sample of current smokers who had smoked in the past month (n = 1573). † Percentages and frequencies exclude refused and “don’t know” responses. ‡ AORs are adjusted for daily smoking status, key sociodemographic variables (age, sex, Indigenous status, labour force status, highest level of education, remoteness and area-level disadvantage), noticing other types of health information, and survey month (in 2-month blocks). P values are reported for overall variable significance, using adjusted Wald tests. § In addition to other covariates, analyses for type of advertising are also adjusted for frequency of advertising recall (often v sometimes or never). |
|||||||||||||||
Tobacco control policies and activities in Aboriginal community-controlled health services
Aboriginal community-controlled health services (ACCHSs) have long recognised tobacco use as an important contributor to poor health outcomes in their communities,1 and have worked to reduce this burden with a range of tobacco control initiatives. The ACCHS sector includes about 150 health services across Australia, each governed and managed by its local Aboriginal community, as well as representative state or territory organisations (Affiliates) and the National Aboriginal Community Controlled Health Organisation (NACCHO).
In 2001, NACCHO surveyed 67 staff from Aboriginal health services, 124 Aboriginal and Torres Strait Islander community members from 13 locations, and 76 health services with predominantly Aboriginal and Torres Strait Islander clients.2 The survey identified high levels of knowledge about the harmful health effects of tobacco, a lack of specific tobacco control programs and the need for more information on effective stop-smoking interventions. The report recommended that governments prioritise and fund tobacco control through policies that deal with social determinants of smoking, workforce training, comprehensive long-term programs to reduce smoking, and ongoing evaluation. For ACCHSs, the report recommended making tobacco control a specific priority and integrating it into health service programs.
Since 2001, specific tobacco control programs have been widely implemented in ACCHSs, informed by evidence from individual evaluations and randomised controlled trials of Aboriginal tobacco control interventions,3–5 and literature reviews.6–9 ACCHSs have also learnt from each other by sharing examples of what has (or has not) worked well.10–12
In 2008, the federal government increased support through the $14.5 million Indigenous Tobacco Control Initiative over 3 years, followed in 2009 by a $100.6 million commitment over 4 years to the Council of Australian Governments’ Tackling Indigenous Smoking measure.13,14 These funded social marketing, quit support and other programs, with the goal of halving smoking rates in Aboriginal and Torres Strait Islander communities by 2018. Forty ACCHSs and three NACCHO Affiliates received funds for tobacco control activities under these initiatives. Smoke-free workplace policies for ACCHSs and other organisations delivering Aboriginal primary health care were mandated in funding contracts with the Australian Government from July 2012.15
These tobacco control activities occurred in the wider Australian context of expanding smoke-free legislation, increases in tobacco taxation, plain packaging of cigarettes and ongoing social marketing campaigns.
The Talking About the Smokes (TATS) project, part of the International Tobacco Control Policy Evaluation Project, aims to assess the impact of tobacco control policies on the Aboriginal and Torres Strait Islander population. Here, we describe the tobacco control policies, activities and programs reported by the ACCHSs participating in the TATS project.
Methods
The TATS project involved 35 communities served by 34 ACCHSs and one community in the Torres Strait where there is no ACCHS and health services are provided by Queensland Health. ACCHSs were selected to reflect the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. The methods are described in detail elsewhere.16,17
Briefly, at 30 sites, we aimed to survey up to 50 smokers or ex-smokers who had quit ≤ 12 months before and 25 non-smokers, with equal numbers of men and women and those aged 18–34 years and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. Between April 2012 and October 2013, trained local interviewers completed the 30–60 minute community surveys face to face using a computer tablet. The community sample closely matched the distribution of age, sex, jurisdiction, remoteness and number of cigarettes smoked per day reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17
The TATS project also invited representatives at each site to complete a single policy monitoring survey, including questions about health service size and location; tobacco control funding, resources and policies; cessation support; and advocacy. The policy monitoring surveys were paper-based, designed to take less than 10 minutes, and were completed by staff members selected by the ACCHS. Policy monitoring surveys were completed while community surveys were being conducted at that site. Questions from the policy monitoring and community surveys analysed here are listed in Appendix 1.
The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.
Statistical analyses
We report the numbers of ACCHSs with different levels of tobacco control resourcing, activities and smoke-free policies; and the percentage and frequency of community members supporting smoking bans. Using the χ2 test, we assessed variation between services by size of service (< 50 or ≥ 50 staff); whether the service had received dedicated tobacco control funding in the past year; and its reported prioritisation of tobacco control in the past year (“not at all”, “just a little”, “a fair amount” or “a great deal”).
At the first project site, the question about prioritisation of tobacco control was not asked, and two questions about dispensing and prescribing free nicotine replacement therapy were asked as a single question. Less than 0.5% of respondents to the community survey did not answer the questions about smoking bans. These missing values were excluded from our analyses. We also excluded results from the Torres Strait community without an ACCHS.
Results
The 32 completed policy monitoring surveys describe tobacco control activities at 34 sites, as a single survey was completed by the umbrella ACCHS for three participating sites in one area. Nineteen services had 50 or more staff and 13 had fewer than 50.
Tobacco control resourcing and activities at ACCHSs
Nineteen of 32 ACCHSs reported receiving specific funding for tobacco control programs in the past 12 months. Another three used untied funds for tobacco control programs. Dedicated tobacco control funding was not associated with the size of the ACCHS (P = 0.84) or its reported prioritisation of tobacco control (P = 0.19). Thirteen ACCHSs reported prioritising tobacco control a great deal, 11 a fair amount and seven just a little. Eighteen ACCHSs had a staff position with a major focus on tobacco control.
Staff of 27 services had attended tobacco control training in the past year. There was no association between staff attending training and the size of the service (P = 0.31) or dedicated tobacco control funding (P = 0.34). However, there was an association with the prioritisation of tobacco control (P = 0.04), with some staff attending training at all 13 ACCHSs that had prioritised it a great deal. The training had been provided by a range of organisations, including NACCHO Affiliates, the Centre for Excellence in Indigenous Tobacco Control, cancer councils, quit organisations and state health departments.
In the past 12 months, 17 of 32 services had run programs to help people quit smoking. These included Aboriginal-specific tobacco control and healthy lifestyle programs, as well as mainstream quit programs. In all but one of these services, Aboriginal health workers or tobacco action workers were involved in running the program. Programs had been evaluated in nine services, some with internal surveys and others with the assistance of NACCHO Affiliates or universities.
Free nicotine replacement therapy was prescribed or dispensed by 25 of the 32 services. Most ACCHSs (21/34) supported staff who smoked by providing them with extra smoking cessation support, either by facilitating access to programs available to clients or through specific programs for staff.
Smoke-free workplace policies
All ACCHSs reported having a formal smoke-free policy in place. The features of these policies and the reported levels of adherence are described in Box 1. In contrast, only 18 of 32 services reported that most or all other Aboriginal and Torres Strait Islander organisations in their community were smoke-free; 10 reported that some were smoke-free and four that none were.
Community survey respondents (n = 2435) reported a high level of support for smoking bans everywhere at ACCHSs and indoors at other Aboriginal organisations, with less (but still majority) support for bans at outdoor community events (Box 2). Among the daily smokers who did not support total bans at ACCHSs, 82% (251/306) supported indoor bans. Daily smokers were least likely to support any of the bans.
Health promotion
All 32 ACCHSs provided locally or externally produced quit-smoking information to their communities, most commonly using posters, pamphlets and displays at information days or other community events, but also using newer media such as the internet and social media (Box 3). Health services with dedicated tobacco control funding were more likely to use locally developed posters (P = 0.03) and pamphlets (P = 0.02) in the clinic, and to give pamphlets to other organisations (P = 0.02), but there were no significant associations with funding when these locally developed items were considered together with externally developed information, or for other types of information. Ten services reported smoking or quitting stories featuring someone from their health service in mainstream or Aboriginal and Torres Strait Islander television, radio or newspaper news.
Nineteen ACCHSs reported discussing tobacco control policy at meetings with government and non-government organisations in the previous year, with 11 reporting that they had influenced local, regional or national tobacco control policy.
Discussion
We found that tobacco control initiatives are a priority in ACCHSs, with all reporting smoke-free workplace policies to reduce smoking and exposure to second-hand smoke. Staff with specific tobacco control training are providing a range of evidence-informed quit-smoking programs in health services and in the wider Aboriginal and Torres Strait Islander community. This increased tobacco control activity was not just found in health services with dedicated Aboriginal and Torres Strait Islander tobacco control funding.
Elsewhere in this supplement, we show that more community members from sites with dedicated tobacco control resources had been advised to quit,18 recalled noticing cigarette pack warning labels,19 made quit attempts20 and used stop-smoking medicines21 than those from sites without dedicated resources. However, there were no such significant differences for wanting to quit,22 smoke-free homes,23 recalling advertising and news stories about smoking and quitting,19 and personal attitudes towards smoking.24
A limitation to our study is that although the selected ACCHSs are geographically representative of the Aboriginal and Torres Strait Islander population, the ACCHSs that responded to the call for participation are likely to be biased towards those that were more interested and active in tobacco control. Further, the people completing the policy survey may have been unaware of all services and policies or may have overstated what was being provided. It was difficult to categorise services by their level of tobacco control activity because of the differences in the range of activities offered. Consequently, it was not possible to detect a relationship between dedicated funding and level of tobacco control activity. Furthermore, the small number of health services in our study did not allow identification of enablers and barriers to services prioritising tobacco control work, a useful area to explore in future research.
Our findings on smoke-free policies are not surprising, given implementing smoke-free work environments became a condition of funding for ACCHSs at the same time this study was conducted.15 However, it is likely that some aspects of these policies pre-dated the funding requirement, given that all 76 Aboriginal health services surveyed in 2001 reported indoor smoking bans, with the policies of 32% of services including broader measures.2 Our results provide evidence that many ACCHSs have more comprehensive policies, such as banning staff from smoking with clients and other staff or where they can be seen or while in uniform, and the provision of cessation support for staff. The incremental approach of ACCHSs in developing and strengthening policy content and implementation has common ground with government approaches to tobacco control, where success with indoor smoking bans was followed by an emphasis on initial exceptions, such as pubs and prisons, and on outdoor areas such as outdoor dining areas and street malls.25
The high level of community support for smoking bans that we found may reflect the wider tobacco control environment and the active involvement of ACCHS managers, staff and the community in tobacco control over the preceding decade. ACCHSs reported that policies relating to smoking behaviour of Aboriginal staff and the community have evolved over time, as the measures have been contested and negotiated in various Aboriginal community forums. This has included discussions about the right to smoke and the right to be protected from second-hand smoke, the social inclusion of sharing cigarettes and the significance of denormalising smoking and modelling healthier behaviour to children.11,26
The relatively small size of many ACCHSs provides an environment to test out policy measures that can then be either discarded as unacceptable or ineffective, or promoted as successful measures to other Aboriginal, community and health organisations. A key characteristic of ACCHSs is that a community with a high prevalence of smoking is involved in making and implementing decisions in areas they can control, such as workplaces and community events, thus providing Aboriginal leadership and contributing to shifts in social norms in their community. Aboriginal health services are well placed to influence social norms because of the large number of Aboriginal and Torres Strait Islander people who work there and use their services — 3618 full-time equivalent staff and 314 000 clients in 2012–13.27 There is an opportunity for ACCHSs to influence other Aboriginal and Torres Strait Islander organisations in their communities that do not have smoke-free policies.
It would be useful to monitor the diffusion of the successful and innovative tobacco control work both within and beyond the ACCHS sector, and to look to ACCHSs for new ideas in the future. The high level of commitment and experience in ACCHSs provides a strong base for sustainable interest and activity to further reduce smoking levels and smoking-related harm.
1 Smoke-free policies at health services (n = 32)
|
Policy details |
Health services |
||||||||||||||
|
|
|||||||||||||||
|
Policy content |
|||||||||||||||
|
No smoking indoors |
32 |
||||||||||||||
|
Designated outdoor smoking area |
12 |
||||||||||||||
|
No smoking indoors or outdoors within the boundary/fence of health service |
28 |
||||||||||||||
|
No smoking in work vehicles |
32 |
||||||||||||||
|
No smoking in health service uniform |
18 |
||||||||||||||
|
No smoking in work time |
9 |
||||||||||||||
|
Other* |
5 |
||||||||||||||
|
How the policy was communicated |
|||||||||||||||
|
Written policy |
32 |
||||||||||||||
|
Signs |
28 |
||||||||||||||
|
Staff meetings and/or newsletters |
25 |
||||||||||||||
|
How many staff and clients follow all elements of the policy |
|||||||||||||||
|
Almost all |
17 |
||||||||||||||
|
Most |
11 |
||||||||||||||
|
Some |
3 |
||||||||||||||
|
Only a few |
1 |
||||||||||||||
|
|
|||||||||||||||
|
* Such as no staff smoking with clients or other staff, when offsite in an official capacity or outside designated meal breaks. |
|||||||||||||||
2 Aboriginal and Torres Strait Islander community support for smoke-free environments (n = 2435)*
|
Smoking ban |
Daily smokers (n = 1342) |
Non-daily smokers (n = 233) |
Ex-smokers (n = 299) |
Never-smokers (n = 561) |
|||||||||||
|
|
|||||||||||||||
|
Smoking should be banned everywhere at ACCHSs |
77% (1030) |
85% (197) |
85% (255) |
87% (487) |
|||||||||||
|
Smoking should be banned indoors at other Aboriginal organisations |
93% (1242) |
93% (217) |
95% (284) |
97% (544) |
|||||||||||
|
Smoking should be banned at outdoor festivals and sporting events |
51% (687) |
70% (163) |
65% (194) |
71% (398) |
|||||||||||
|
|
|||||||||||||||
|
ACCHSs = Aboriginal community controlled health services. * Results are based on the respondents who “agree” or “strongly agree” with each statement and exclude those who did not answer. |
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3 Health services using different media to disseminate quit-smoking information (n = 32)
|
Quit-smoking information |
Health services |
||||||||||||||
|
|
|||||||||||||||
|
Posters in clinic |
31 |
||||||||||||||
|
Pamphlets in clinic |
29 |
||||||||||||||
|
Health information days and events |
28 |
||||||||||||||
|
Displays at other community events |
26 |
||||||||||||||
|
Posters in other community locations |
23 |
||||||||||||||
|
Pamphlets given to other organisations |
21 |
||||||||||||||
|
Newsletters |
18 |
||||||||||||||
|
Website |
14 |
||||||||||||||
|
Social media |
12 |
||||||||||||||
|
Newspaper or community magazine |
11 |
||||||||||||||
|
Local radio advertisement |
11 |
||||||||||||||
|
CD/DVD |
11 |
||||||||||||||
|
Local television advertisement |
2 |
||||||||||||||
|
Mobile phone messages |
2 |
||||||||||||||
Social acceptability and desirability of smoking in a national sample of Aboriginal and Torres Strait Islander people
Smoking is partly motivated by social factors, although the strength of this influence has declined as smoking has become less socially normative in the community.1,2 Social norms have two aspects: social acceptability, or the contexts where the behaviour is accepted, and social desirability, or the extent to which it is valued. Separating the two can be difficult in practice.
Challenging normative beliefs was a focus of community-based programs to reduce the smoking rate and burden of tobacco-related disease among Aboriginal and Torres Strait Islander communities,3 as part of the 2009 National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.4 In particular, these programs tackled the social desirability and acceptability of smoking in contexts where the smoke affects other people. There has been very little published research to guide this approach.
In the broader Australian population, most smokers (86%) agree that society disapproves of smoking,5 which is an indication that smoking is no longer socially acceptable in certain situations. In contrast, the high prevalence of smoking in Aboriginal and Torres Strait Islander peoples (42% in those aged 15 years or older)6 contributes to beliefs that smoking is normal, expected or intergenerational.7–12 This suggests a certain level of acceptability but does not necessarily indicate whether smoking is socially desirable or valued.
The negative impact of tobacco use on Aboriginal and Torres Strait Islander families appears to reduce the desirability of smoking.7 In particular, the importance of protecting others from the harms of second-hand smoke and setting an example to children are said to provide strong motivation to quit.7,13,14 Parents, older relatives, health staff and elders have been identified as important anti-tobacco role models for Aboriginal and Torres Strait Islander youth.7–9
However, there is evidence that smoking is also valued within Aboriginal and Torres Strait Islander networks, among which smoking and sharing tobacco are associated with connectedness, affirmation of cultural identity and the opportunity to talk through problems.7,9,11–13,15,16 The strength of these competing values and their influence on quitting has not been previously investigated.
Here, we describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander peoples, and assess the relationship of these beliefs with quitting.
Methods
Survey design and participants
We used data from the Talking About The Smokes (TATS) project, which conducted baseline surveys of 2522 Aboriginal and Torres Strait Islander people (1643 current smokers, 311 ex-smokers and 568 never-smokers) from April 2012 to October 2013. The survey design and participants have been described in detail elsewhere.17,18
Briefly, the study used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. These project sites were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers (or ex-smokers who had quit ≤ 12 months previously) and a smaller sample of 25 non-smokers, with equal numbers of men and women, and those aged 18–34 and ≥ 35 years. The sample sizes were doubled in four major urban sites and the Torres Strait. People were excluded if they were less than 18 years old, were not usual residents of the area, were staff of the ACCHS, or were deemed unable to consent or complete the survey.
In each site, different locally determined methods were used to collect a representative, albeit non-random, sample. The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and number of cigarettes smoked per day (for current daily smokers). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17
Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, took 30–60 minutes to complete. A single survey of health service activities was also completed for each site.
The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.
ITC Project comparison sample
The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Comparisons were made with smokers in the general Australian population using data from the Australian ITC project, which surveyed 1010 daily smokers between September 2011 and February 2012 (Wave 8.5). Participants of the Australian ITC project were recruited by random digit telephone dialling from within strata defined by jurisdiction and remoteness.19 While baseline surveys were completed over the telephone, follow-up surveys could be completed online. Our comparisons are for daily smokers only, due to slightly different definitions of non-daily smokers between the TATS project and ITC Project surveys.
Outcome measures
Survey questions were based on previous Australian ITC Project surveys, but with added questions about specific concerns and in language better reflecting Aboriginal and Torres Strait Islander colloquial speech. Eight questions assessed normative beliefs, all of which used a five-point scale ranging from “strongly agree” to “strongly disagree” (plus a “don’t know” response, which was later merged with “neither agree nor disagree”, and a “refused” option, which was excluded from analysis).
Two quit-related outcomes were used: wanting to quit, and having attempted to quit in the past year, which was derived from questions on ever having tried to quit and how long ago the most recent quit attempt occurred. The exact survey questions are presented in Appendix 1.
Statistical analyses
We calculated percentages and frequencies for all normative belief items. ITC Project data were summarised using percentages and 95% confidence intervals, directly standardised to match the age and sex profile of Aboriginal and Torres Strait Islander smokers according to the 2008 NATSISS.
For TATS project outcomes, variation by smoking status was investigated with simple logistic regression. Multivariable logistic regression was used to assess the association of each normative belief with wanting and attempting to quit, adjusted for daily smoking status and key sociodemographic variables. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the TATS Project sampling design, identifying the 35 project sites as clusters and the age–sex quotas as strata.20
For questions about normative beliefs, data were excluded for less than 1% of participants due to missing or refused responses. For associations with wanting to quit, we excluded a further 79 smokers (4.8%) who did not know if they wanted to quit; and for associations with quitting in the past year, we excluded 21 (1.3%) who did not know when their last quit attempt occurred (if ever).
Results
Normative beliefs
Aboriginal and Torres Strait Islander daily smokers were less likely than those in the general Australian population to perceive that mainstream society disapproves of smoking (62% v 78.5%) (Box 1). Among all Aboriginal and Torres Strait Islander respondents, higher proportions agreed that society disapproves of smoking than agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking (62% v 41%).
While similar proportions of daily and non-daily smokers agreed that mainstream society disapproves of smoking, non-daily smokers were more likely to agree that Aboriginal and Torres Strait Islander community leaders where they live disapprove (odds ratio [OR], 1.50; 95% CI, 1.10–2.05; P = 0.01). Close to two-thirds of smokers and recent quitters agreed there are now fewer places where they feel comfortable smoking, with little variation by smoking status. Although a minority of respondents said non-smokers miss out on all the gossip, this belief was more common among non-daily smokers (OR, 1.46; 95% CI, 1.01–2.10; P = 0.04) than daily smokers. Most Aboriginal and Torres Strait Islander respondents (90% or more) reported that being a non-smoker sets a good example to children, with no clear difference by smoking status. Finally, there was overwhelming support (80% or higher) for the government doing more to tackle the harm to Aboriginal and Torres Strait Islander peoples caused by smoking. This was significantly higher than the level of support for government action among the general Australian population (47.2%).
Few non-smokers said they were excluded by smokers or pressured by smokers to take up smoking (Box 2). Ex-smokers who had stopped smoking within the past year (but not those who had been quit for more than 1 year) were more likely to say they were pressured to smoke (OR, 1.99; 95% CI, 1.09–3.61; P = 0.04) than those who had never smoked.
Relationship between normative beliefs and quitting
Among smokers, all five anti-smoking beliefs were associated with wanting to quit, and all except perceived societal disapproval of smoking were also associated with having attempted to quit in the past year (Box 3). The only pro-smoking belief, that non-smokers miss out on all the gossip or yarning, was not associated with either wanting or attempting to quit.
Discussion
We found that Aboriginal and Torres Strait Islander smokers are less likely than smokers in the broader Australian population to believe that society views smoking as socially unacceptable. This difference is likely to be a product of higher smoking prevalence, but it may also reinforce it — lower perceived social acceptability of smoking was associated with wanting and attempting to quit, as has been found in other settings.21–24 In contrast, personal attitudes towards smoking (regretting starting to smoke, perceiving it to be too expensive, enjoying it, seeing it as an important part of life and smoking for stress management) do not appear to be driving differences in quitting.25
One possible interpretation of this pattern of results is that social norms are more influential in collectivist societies, in which behaviour is shaped to a greater degree by societal than personal needs.24,26,27 There is a growing body of evidence that protecting others provides strong motivation for Aboriginal and Torres Strait Islander peoples to quit,7,13,14,28 reflected here in the particular salience and influence of believing non-smokers set a good example to children. Similar findings were reported for Maori and Pacific peoples in the New Zealand ITC Project,26 which recommended greater emphasis on social reasons to quit, such as setting an example to children. For those who work in comprehensive primary health care settings, messages framed in ways that emphasise protecting others are likely to motivate quitting for Aboriginal and Torres Strait Islander peoples who smoke.
However, while this may be a more effective means of motivating people to quit, the implications for sustaining quit attempts are unclear. Current behaviour change theory suggests that quitting may be more difficult to sustain when motivated by social influences (including concern for others), given the likely challenges by internal needs such as biological or psychological dependence.2 General practitioners and others who provide cessation help should not discount the possibility that more dependent smokers may require support to manage cravings or urges to smoke upon quitting. Sustaining a quit attempt in the face of additional challenges, some of which are specific to the context of quitting for Aboriginal and Torres Strait Islander smokers, is an important area for future research.29
Our finding that quitting among Aboriginal and Torres Strait Islander smokers appears to be more influenced by their perceptions that local community leaders disapprove of smoking than by disapproval by mainstream society is important. In other settings, norms from significant others are more influential on cigarette consumption and motivation to quit than are mainstream societal norms.24 In this context, significant others may include distant relatives and respected community leaders, who have been described as influential in decisions about starting to smoke among Aboriginal and Torres Strait Islander youth.7–9 This offers one explanation for the motivational effect of local Aboriginal and Torres Strait Islander leaders, although we were unable to assess whether these constructs overlap.
Further, while the survey measured perceptions about disapproval of smoking by local leaders, our findings nonetheless have implications for tobacco control leadership, and the importance of community leadership in particular. We can draw from examples of indigenous leadership and participation across all areas of tobacco control in New Zealand,30 where strong national and local Maori leadership, targeted messages and Maori approaches are seen as critical for Maori tobacco-free advances.31 There are also an increasing number of examples of community leadership in Aboriginal and Torres Strait Islander tobacco control. A 2012–2013 survey of 47 Australian organisations involved in the development of tobacco control messages for Aboriginal and Torres Strait Islander peoples showed that 32% targeted elders in these messages.32 Social marketing and other strategies that directly involve local community leaders, or shift perceptions about the beliefs of community leaders, offer a means of reinforcing beliefs that smoking is socially unacceptable and therefore strengthening motivation to quit.
We found strong support for government action to tackle the harm caused by smoking. Resistance to tobacco control is therefore not a plausible explanation for differences in quitting between Aboriginal and Torres Strait Islander peoples and other Australians. There have been similar findings for other high-prevalence populations.33
Further, while smoking may be considered somewhat more normal among Aboriginal and Torres Strait Islander smokers, we found no evidence of social norms that indicate smoking is strongly socially valued or desirable. In contrast to previous evidence that suggests social isolation of non-smokers contributes to the high smoking prevalence among Aboriginal and Torres Strait Islander peoples,7,9,12,13,16 we found that most non-smokers did not feel excluded by smokers or pressured to smoke, or that they missed out on gossip. Further, even among smokers who believed that non-smokers missed out, we found no evidence that this presents a major barrier to quitting activity.
Strengths and limitations
The TATS project dataset provides the first national, broadly representative record of normative beliefs about smoking among Aboriginal and Torres Strait Islander smokers and non-smokers.
However, this study has some limitations. Analyses of associations between normative beliefs and quitting excluded 4.8% of smokers who did not know if they wanted to quit and 1.3% who could not recall how long ago their most recent quit attempt occurred. While this removes uncertainties regarding the categorisation of “don’t know” responses into yes/no outcomes, it also excludes a small proportion of Aboriginal and Torres Strait Islander people who may differ from included participants.
It is possible that we missed important normative beliefs that have additional influences. In particular, we did not ask specific questions about beliefs of family. This was because the diversity of family structures and a varying tendency to include distant relatives requires more extensive questioning than we had capacity for.
While it is possible that some of the differences found may be due to culturally moderated social desirability biases, we attempted to minimise the potential for this by engaging local interviewers.34 Tobacco control research in other settings suggests that survey responses about wanting to quit are not subject to greater social desirability biases when collected face to face.35
We also stress that the associations presented should not be interpreted as being causal. We cannot determine from these results alone whether negative beliefs about the social acceptability and desirability of smoking motivate quitting, or whether those motivated to quit are more likely to express negative views. While these limitations complicate our interpretations, the hypothesised causal links are strengthened by prospective research in other settings.21–24
Finally, comparisons with ITC Project data must be made with a degree of caution, given differences in methods and timing of recruitment and data collection. However, the differences we report here are too large to be accounted for by these factors.
In conclusion, tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.
1 Social normative beliefs about smoking among daily smokers in the Australian population and among a national sample of Aboriginal and Torres Strait Islander people, by smoking status*
|
Australian ITC Project† |
Talking About The Smokes project‡ |
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|
Normative belief§ |
Daily smokers (n = 1010) |
Daily smokers (n = 1392) |
Non-daily smokers (n = 251) |
Ex-smokers (n = 311) |
Never-smokers (n = 568) |
||||||||||
|
|
|||||||||||||||
|
[Mainstream] society disapproves of smoking |
|||||||||||||||
|
Strongly agree or agree |
78.5% (73.3%–82.9%) |
62% (851) |
65% (164) |
62% (190) |
62% (351) |
||||||||||
|
Neither agree nor disagree, or don’t know |
10.6% (7.9%–13.9%) |
24% (336) |
22% (56) |
22% (67) |
24% (138) |
||||||||||
|
Disagree or strongly disagree |
11.0% (7.4%–15.9%) |
14% (196) |
12% (31) |
17% (52) |
14% (78) |
||||||||||
|
Aboriginal and/or Torres Strait Islander community leaders where you live disapprove of smoking |
|||||||||||||||
|
Strongly agree or agree |
— |
40% (547) |
50% (124) |
43% (133) |
38% (218) |
||||||||||
|
Neither agree nor disagree, or don’t know |
— |
33% (453) |
24% (60) |
29% (88) |
36% (205) |
||||||||||
|
Disagree or strongly disagree |
— |
28% (380) |
26% (66) |
28% (87) |
26% (145) |
||||||||||
|
There are fewer and fewer places you (would) feel comfortable smoking¶ |
|||||||||||||||
|
Strongly agree or agree |
— |
70% (970) |
65% (163) |
65% (51) |
— |
||||||||||
|
Neither agree nor disagree, or don’t know |
— |
14% (192) |
14% (35) |
13% (10) |
— |
||||||||||
|
Disagree or strongly disagree |
— |
16% (220) |
21% (52) |
22% (17) |
— |
||||||||||
|
Non-smokers miss out on all the good gossip/yarning |
|||||||||||||||
|
Strongly agree or agree |
— |
27% (379) |
36% (89) |
29% (89) |
23% (131) |
||||||||||
|
Neither agree or disagree, or don’t know |
— |
18% (246) |
16% (41) |
8% (26) |
14% (81) |
||||||||||
|
Disagree or strongly disagree |
— |
55% (758) |
48% (121) |
63% (194) |
63% (356) |
||||||||||
|
Being a non-smoker sets a good example to children |
|||||||||||||||
|
Strongly agree or agree |
— |
90% (1246) |
94% (236) |
95% (292) |
95% (541) |
||||||||||
|
Neither agree nor disagree, or don’t know |
— |
5% (70) |
2% (5) |
2% (6) |
3% (15) |
||||||||||
|
Disagree or strongly disagree |
— |
5% (67) |
4% (10) |
4% (11) |
2% (11) |
||||||||||
|
The government should do more to tackle the harm [done to Aboriginal and Torres Strait Islander people] that is caused by smoking |
|||||||||||||||
|
Strongly agree or agree |
47.2% (41.6%–52.8%) |
80% (1108) |
86% (215) |
89% (270) |
84% (465) |
||||||||||
|
Neither agree nor disagree, or don’t know |
21.6% (17.5%–26.3%) |
13% (173) |
9% (23) |
6% (17) |
12% (65) |
||||||||||
|
Disagree or strongly disagree |
31.3% (25.8%–37.3%) |
7% (101) |
5% (12) |
6% (18) |
4% (24) |
||||||||||
|
|
|||||||||||||||
|
ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses. † Results are percentages (95% confidence intervals) for daily smokers from Wave 8.5 (September 2011 – February 2012) of the Australian ITC Project, directly standardised to the age and sex of Aboriginal and Torres Strait Islander smokers surveyed in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results are percentages (frequencies) for the baseline sample of Aboriginal and Torres Strait Islander people in the Talking About The Smokes project (April 2012–October 2013). § Text in square brackets was not included in Australian ITC Project survey questions. ¶ Asked of smokers and recent quitters only. |
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2 Social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander non-smokers*
|
Normative belief |
Ex-smokers quit |
Ex-smokers quit |
Never-smokers (n = 568) |
||||||||||||
|
|
|||||||||||||||
|
You are excluded from things because you are a non-smoker (now) |
|||||||||||||||
|
Strongly agree or agree |
27% (21) |
25% (58) |
24% (137) |
||||||||||||
|
Neither agree nor disagree |
8% (6) |
6% (14) |
13% (73) |
||||||||||||
|
Disagree or strongly disagree |
65% (51) |
69% (159) |
63% (358) |
||||||||||||
|
You are pressured by smokers to take up smoking (again) |
|||||||||||||||
|
Strongly agree or agree |
26% (20) |
13% (29) |
15% (84) |
||||||||||||
|
Neither agree nor disagree |
3% (2) |
4% (10) |
8% (43) |
||||||||||||
|
Disagree or strongly disagree |
72% (56) |
83% (192) |
78% (441) |
||||||||||||
|
|
|||||||||||||||
|
* Results are percentages (frequencies) for the baseline sample in the Talking About The Smokes project (April 2012–October 2013) and exclude refused responses. |
|||||||||||||||
3 Association of social normative beliefs about smoking with wanting and attempting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*
|
Want to quit |
Attempted to quit in the past year |
||||||||||||||
|
Normative belief |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
|||||||||
|
|
|||||||||||||||
|
Mainstream society disapproves of smoking |
|||||||||||||||
|
Neutral or disagree |
65% (374) |
1.0 |
0.01 |
46% (279) |
1.0 |
0.05 |
|||||||||
|
Agree |
73% (709) |
1.49 (1.10–2.01) |
51% (514) |
1.26 (1.00–1.60) |
|||||||||||
|
Aboriginal and/or Torres Strait Islander community leaders where you live disapprove of smoking |
|||||||||||||||
|
Neutral or disagree |
64% (578) |
1.0 |
< 0.001 |
46% (431) |
1.0 |
0.001 |
|||||||||
|
Agree |
77% (504) |
1.94 (1.50–2.52) |
54% (360) |
1.43 (1.16–1.77) |
|||||||||||
|
There are fewer and fewer places you feel comfortable smoking |
|||||||||||||||
|
Neutral or disagree |
64% (302) |
1.0 |
0.01 |
46% (224) |
1.0 |
0.03 |
|||||||||
|
Agree |
72% (781) |
1.45 (1.09–1.93) |
51% (569) |
1.33 (1.03–1.71) |
|||||||||||
|
Non-smokers miss out on all the good gossip/yarning |
|||||||||||||||
|
Neutral or disagree |
70% (769) |
1.0 |
0.95 |
49% (564) |
1.0 |
0.70 |
|||||||||
|
Agree |
70% (314) |
1.01 (0.75–1.36) |
50% (229) |
1.05 (0.82–1.34) |
|||||||||||
|
Being a non-smoker sets a good example to children |
|||||||||||||||
|
Neutral or disagree |
37% (54) |
1.0 |
< 0.001 |
33% (50) |
1.0 |
0.001 |
|||||||||
|
Agree |
73% (1029) |
4.92 (2.98–8.12) |
51% (743) |
2.11 (1.37–3.24) |
|||||||||||
|
The government should do more to tackle the harm done to Aboriginal and Torres Strait Islander people that is caused by smoking |
|||||||||||||||
|
Neutral or disagree |
51% (149) |
1.0 |
< 0.001 |
42% (129) |
1.0 |
0.009 |
|||||||||
|
Agree |
74% (934) |
3.03 (2.17–4.23) |
51% (663) |
1.48 (1.10–1.98) |
|||||||||||
|
|
|||||||||||||||
|
OR = odds ratio. * Results are based on the baseline sample of current smokers (n = 1643) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses (for all variables) and “don’t know” responses (for quitting outcomes only). ‡ ORs are adjusted for daily smoking status and key sociodemographic variables (age, sex, identification as Aboriginal and/or Torres Strait Islander, labour force status, highest level of education, remoteness and area-level disadvantage). § P values are reported for overall variable significance, using adjusted Wald tests. |
|||||||||||||||