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
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) |
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|
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. |
|||||||||||||||
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. |
|||||||||||||||
Personal attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters
Contemporary theories of smoking and other addictive behaviours see attitudes as one set of forces influencing behaviour.1,2 Negative attitudes towards smoking, such as those about its high cost or regret about starting to smoke, are associated with increased interest in quitting and attempts to quit,3–5 but perhaps not with sustained abstinence.6,7 These attitudes compete with the benefits attributed to smoking, which have been shown to predict continued smoking and relapse.8–10 Identifying attitudes that influence behaviour contributes to our understanding of what motivates and sustains quitting. This may differ between social and cultural environments, affecting which tobacco control policies work to reduce smoking.4,11
There is no nationally representative research that explores attitudes towards smoking among Aboriginal and Torres Strait Islander people. It is plausible that part of the reason for the high daily smoking prevalence, which was over double that of the non-Indigenous population in 2012–2013,12 is that Aboriginal and Torres Strait Islander people hold more positive attitudes and/or fewer negative beliefs about smoking. It is also theorised that thoughts about quitting may be cast aside in stressful circumstances, when motivation shifts from future goals to immediate priorities,2,13 which may be seen to be alleviated by benefits of smoking. Benefits of smoking described by Aboriginal and Torres Strait Islander peoples include coping with stress,14–21 providing belonging and connectedness,15,17,19–22 reinforcing sharing and reciprocity,15,17,19,21 and creating opportunities for yarning or talking through problems.14,15,17,19–21 Though concern about the high cost of smoking does not feature heavily in Aboriginal tobacco control literature, it is reported as one of the top motivators to quit among the general Australian population.23
Here, we describe attitudes towards smoking among a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters, assess their association with quitting among smokers, and compare these attitudes with those among smokers in the general Australian population.
Methods
Survey design and participants
The Talking About The Smokes (TATS) project surveyed 1643 current smokers and 78 ex-smokers who had quit ≤ 12 months previously, from April 2012 to October 2013 (Wave 1, or baseline). The survey design and participants are described in detail elsewhere.24,25
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 (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 (those who had quit within the past 12 months), with equal numbers of men and women, and those aged 18–34 years and ≥ 35 years. The sample sizes were 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 less than 18 years old, were not usual residents of the area, were staff of the ACCHS, or were deemed unable to complete the survey. In each location, different locally determined methods were used to collect a representative, albeit non-random, sample (eg, surveying Aboriginal or Torres Strait Islander households, opportunistic event-based sampling, snowball sampling using established contacts).
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. The baseline sample closely matched the distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and also for 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.24 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 results from the Australian ITC Project, which surveyed 1017 daily smokers between July 2010 and May 2011 (Wave 8), and 1010 daily smokers between September 2011 and February 2012 (Wave 8.5). Participants of the Australian ITC Project were adult smokers who were recruited by random digit telephone dialling from within strata defined by jurisdiction and remoteness.26,27
The ITC Project sample mostly comprised those recontacted from previous survey waves, in addition to smokers who were newly recruited to replace those lost to follow-up (Wave 8, 14.6%; Wave 8.5, 17.8%). While baseline surveys were completed over the telephone, follow-up surveys could be self-administered online (Wave 8, 29.6%; Wave 8.5, 32.1%). 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 have concentrated on daily smokers in our analyses.
Outcome measures
Survey questions were based on ITC Project surveys, particularly the Australian ITC Project surveys. The exact questions used for this article are presented in Appendix 1.
Eight questions measured attitudes towards smoking, all of which captured responses using a five-point scale from “strongly agree” to “strongly disagree” (plus a “don’t know” response, which was later merged with “neither agree nor disagree”). Five of these questions are reported here for smokers, and three for recent quitters.
Two outcomes were used to assess quitting: 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.
Statistical analyses
We summarised the TATS project and ITC Project survey results using descriptive statistics. ITC Project data were directly standardised to match the age and sex profile of Aboriginal and Torres Strait Islander smokers according to the 2008 NATSISS. Given that our sample was not randomly selected, we did not calculate standard errors for comparisons of percentages between our data and ITC Project data. Thus, these comparisons do not incorporate calculations for statistical significance, but consider differences that are large and meaningful.
For smokers, we used logistic regression to analyse the five attitudinal outcomes and two outcomes on quitting. Unadjusted odds ratios (ORs) are reported for the five personal attitudes (dichotomised), by daily smoking status, sociodemographic variables, and presence of tobacco control resources at the local health service. For the outcomes on quitting, we report adjusted ORs for the five personal attitudes, controlling for daily smoking status and sociodemographic variables. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the TATS project sampling design in all tests of association, using Stata’s svyset command to identify the 35 project sites as clusters and the quotas based on age and sex as strata.28
Data for less than 1% of participants were excluded due to missing or refused responses. For the associations with wanting to quit, we excluded a further 79 participants (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
Attitudes held by smokers
Comparison with ITC Project data
Most attitudes among Aboriginal and Torres Strait Islander smokers were similar to those assessed for smokers in the general Australian population (Box 1). Most daily smokers reported regret about ever starting to smoke (TATS, 78%; ITC, 81.8%) and agreed that they spent too much money on cigarettes (TATS, 81%; ITC, 83.6%). A lower proportion of Aboriginal and Torres Strait Islander daily smokers (65%) than those in the general Australian population (80.6%) said they enjoyed smoking (Box 1). Though similar proportions of daily smokers agreed that smoking is an important part of their life (TATS, 32%; ITC, 34.6%), a higher proportion of Aboriginal and Torres Strait Islander respondents disagreed with this statement (TATS, 49%; ITC, 37.9%). A high proportion of daily smokers agreed that smoking calms them down when stressed or upset (TATS, 83%; ITC, 80.3%).
Attitudes of Aboriginal and Torres Strait Islander smokers
Non-daily smokers generally held less positive attitudes towards smoking (Appendix 2); compared with daily smokers, they were significantly less likely to say that they enjoy smoking (OR, 0.56; 95% CI, 0.42–0.75; P < 0.001), that smoking is an important part of their life (OR, 0.53; 95% CI, 0.35–0.81; P = 0.004) and that smoking calms them down when stressed (OR, 0.48; 95% CI, 0.35–0.67; P < 0.001). Non-daily smokers were also less likely to report that they spend too much money on cigarettes (OR, 0.28; 95% CI, 0.20–0.39; P < 0.001).
There was little variation in smoker attitudes by sociodemographic and other factors (Appendix 2). Compared with the youngest smokers, those aged 35–44 years were less likely to say they enjoy smoking (OR, 0.64; 95% CI, 0.43–0.93), whereas older smokers were more likely to report that smoking is an important part of their life (P < 0.001). Smokers from areas of the highest level of disadvantage were more likely to report that they enjoy smoking (OR, 1.66; 95% CI, 1.19–2.30) compared with those from the least disadvantaged areas (P = 0.01). Smokers from regional areas (OR, 1.67; 95% CI, 1.27–2.20) and remote or very remote areas (OR, 2.13; 95% CI, 1.49–3.04) were also more likely than those from major cities to report that they enjoy smoking (P < 0.001). Smokers who were not in the labour force (OR, 1.78; 95% CI, 1.32–2.38) were more likely to see smoking as an important part of their life than those who were employed (P < 0.001).
Attitudes about regretting ever starting to smoke, being calmed by smoking when stressed, and spending too much money on cigarettes did not vary according to sociodemographic indicators.
Relationship of smoker attitudes with quitting
The likelihood of wanting to quit or having attempted to quit in the past year was higher for Aboriginal and Torres Strait Islander smokers who regretted starting to smoke and those who said they spend too much money on cigarettes, and lower for smokers who said they enjoy smoking and those who reported that smoking is an important part of their life (Box 2).
Attitudes held by recent quitters
Ex-smokers who had quit within the past 12 months reported positive views about having quit (Box 3). Among these recent quitters, 87% agreed that they have more money since they quit, 74% agreed that they cope with stress at least as well as they did when smoking, and 90% agreed that their life is better now that they no longer smoke.
Discussion
Our results show that Aboriginal and Torres Strait Islander people were less likely than the general Australian population to report positive reasons to smoke and held similar views about the negative aspects of smoking. As negative attitudes to smoking were already common, approaches that seek to change these beliefs are not likely to affect Aboriginal and Torres Strait Islander smoking or quitting rates. In particular, levels of regret for ever starting to smoke were comparable to those seen globally.5,29 We hope this energises and reassures those in comprehensive primary health care settings who face the challenge of prioritising smoking cessation amid other, often pressing, demands.30
It is encouraging that a majority of smokers rejected the idea that smoking is an important part of their life, and that a lower proportion of Aboriginal and Torres Strait Islander smokers compared with those in the general Australian population said they enjoy smoking. As in other populations, smokers who agreed with statements about positive attributes of smoking were less interested in quitting and less likely to attempt to quit.10,31 The ITC Project has found that smokers who hold these positive attitudes are also less likely to quit successfully, but that part of this effect can be explained by differences in measures of nicotine dependence.10 However, factors that predict successful quitting sometimes differ from those that predict quit intentions and attempts.6,7 The complex relationships between attitudes, other factors and successful quitting is an important topic for future prospective research in this population.
Qualitative research has demonstrated broad recognition among Aboriginal and Torres Strait Islander peoples that stress is both a trigger for smoking and a common cause of relapse,14–17,19–21 consistent with international evidence on smoking for stress management.9,10 While we were surprised to find that those who believe smoking reduces their stress were no less motivated to quit, our outcomes were limited to quit attempts and not the success of such attempts. Connections between smoking and stress, or psychological reactions to stress, would benefit from further study using measures shown to be sensitive to the multiple life stressors and high levels of psychological distress experienced by Aboriginal and Torres Strait Islander peoples.32,33 Exploration of supports and strategies that enable successful quitting in the presence of these stressors is also indicated. Research on resilience to stress describes the pride associated with mastering the transition to becoming a non-smoker.16 In our results, most ex-smokers agreed that they cope with stress at least as well as they did when smoking and that their life is better now that they no longer smoke. The reduction in psychological distress that follows quitting is well documented.34,35 Health professionals and cessation resources could work towards extinguishing the myth that smoking reduces stress by replacing it with a more accurate and empowering message that ex-smokers experience less stress and greater quality of life once they quit.
Strengths and limitations
This article provides a broadly nationally representative snapshot of attitudes towards smoking held by Aboriginal and Torres Strait Islander smokers. The use of single items to measure constructs can lack sensitivity but enabled us to enquire about a broad range of topics, using attitudinal and functional utility items that have established validity in other populations.36 While the validity of these items is yet to be established for Aboriginal and Torres Strait Islander peoples, comparable associations with quit-related outcomes provide some evidence of convergent validity.36 However, the limited number of closed-ended questions used here would not have captured the full range of attitudes held by Aboriginal and Torres Strait Islander smokers and may have missed important constructs.
Further, comparisons with ITC Project data must be made with a degree of caution. There is expert consensus that response styles are culturally moderated, meaning that the degree to which social desirability bias affects the tendency to agree or respond using scale extremities can vary according to respondent characteristics.36 Methods of recruitment and data collection also differ between the TATS and ITC projects, which may affect response biases present in each. However, the degree of variation to responses across the eight attitude items provides some evidence against any systematic response preference or bias in our data.
Finally, these results do not provide information about whether negative attitudes towards smoking precede quitting, or whether those who are already making quit attempts tend to develop more negative views about smoking. Our understanding of the likely direction of these relationships is informed by prospective research from other settings, which can be tested using longitudinal data from the follow-up of these baseline results.
With these limitations in mind, our findings add to our understanding of the context of smoking and quitting for Aboriginal and Torres Strait Islander peoples. The finding that their personal attitudes towards smoking are similar to those among the general Australian population, and appear to share the same motivating effects, suggests factors other than personal attitudes are likely to explain the high prevalence of smoking among Aboriginal and Torres Strait Islander people. Future research should consider the effect of structural factors, such as access to services that support quitting, intergenerational effects of colonisation and dispossession, levels of racism and psychological distress, and normalisation of smoking within Aboriginal and Torres Strait Islander social networks.17,19,22,37–39
1 Attitudes towards smoking among smokers in the Australian population and a national sample of Aboriginal and Torres Strait Islander people*
|
Australian ITC Project† |
Talking About The Smokes project‡ |
||||||||||||||
|
Survey question and response |
Daily smokers, |
Daily smokers, % (frequency) |
Non-daily smokers, % (frequency) |
||||||||||||
|
|
|||||||||||||||
|
If you had to do it over again, you would not have started smoking§ |
|||||||||||||||
|
Strongly agree or agree |
81.8% (75.7%–86.6%) |
78% (1081) |
79% (197) |
||||||||||||
|
Neither agree nor disagree |
6.8% (4.3%–10.7%) |
7% (102) |
9% (23) |
||||||||||||
|
Disagree or strongly disagree |
11.4% (7.3%–17.3%) |
15% (200) |
12% (30) |
||||||||||||
|
You spend too much money on cigarettes¶ |
|||||||||||||||
|
Strongly agree or agree |
83.6% (78.4%–87.6%) |
81% (1116) |
54% (134) |
||||||||||||
|
Neither agree nor disagree |
7.4% (5.0%–11.0%) |
8% (110) |
11% (28) |
||||||||||||
|
Disagree or strongly disagree |
9.0% (5.9%–13.5%) |
11% (156) |
35% (87) |
||||||||||||
|
You enjoy smoking§ |
|||||||||||||||
|
Strongly agree or agree |
80.6% (75.8%–84.6%) |
65% (898) |
51% (127) |
||||||||||||
|
Neither agree nor disagree |
10.1% (7.5%–13.6%) |
19% (261) |
20% (49) |
||||||||||||
|
Disagree or strongly disagree |
9.3% (6.3%–13.4%) |
16% (223) |
29% (73) |
||||||||||||
|
Smoking is an important part of your life§ |
|||||||||||||||
|
Strongly agree or agree |
34.6% (29.8%–39.9%) |
32% (444) |
20% (50) |
||||||||||||
|
Neither agree nor disagree |
27.4% (22.5%–33.0%) |
19% (268) |
12% (30) |
||||||||||||
|
Disagree or strongly disagree |
37.9% (32.5%–43.6%) |
49% (670) |
68% (169) |
||||||||||||
|
Smoking calms you down when you are stressed or upset¶ |
|||||||||||||||
|
Strongly agree or agree |
80.3% (75.5%–84.3%) |
83% (1143) |
70% (174) |
||||||||||||
|
Neither agree nor disagree |
11.0% (7.7%–15.7%) |
9% (127) |
13% (33) |
||||||||||||
|
Disagree or strongly disagree |
8.7% (6.6%–11.2%) |
8% (111) |
17% (42) |
||||||||||||
|
|
|||||||||||||||
|
ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses. † Results for daily smokers from Wave 8 (n = 1017) or Wave 8.5 (n = 1010) 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 for the baseline sample of Aboriginal and Torres Strait Islander daily smokers (n = 1392) and non-daily smokers (n = 251) in the Talking About The Smokes project, April 2012 – October 2013. § Australian ITC Project Wave 8.5, September 2011 to February 2012. ¶ Australian ITC Project Wave 8, July 2010 to May 2011. |
|||||||||||||||
2 Association of personal attitudes towards 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 |
||||||||||||||
|
Attitude |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
|||||||||
|
|
|||||||||||||||
|
If you had to do it over again, you would not have started smoking |
|||||||||||||||
|
Neutral or disagree |
52% (176) |
1.0 |
< 0.001 |
38% (131) |
1.0 |
< 0.001 |
|||||||||
|
Agree |
75% (907) |
2.79 (1.96–3.97) |
53% (662) |
1.84 (1.37–2.48) |
|||||||||||
|
You spend too much money on cigarettes |
|||||||||||||||
|
Neutral or disagree |
59% (204) |
1.0 |
< 0.001 |
45% (167) |
1.0 |
0.02 |
|||||||||
|
Agree |
73% (879) |
2.22 (1.59–3.10) |
51% (626) |
1.41 (1.06–1.88) |
|||||||||||
|
You enjoy smoking |
|||||||||||||||
|
Neutral or disagree |
85% (489) |
1.0 |
< 0.001 |
58% (348) |
1.0 |
< 0.001 |
|||||||||
|
Agree |
61% (594) |
0.29 (0.21–0.42) |
44% (445) |
0.56 (0.44–0.70) |
|||||||||||
|
Smoking is an important part of your life |
|||||||||||||||
|
Neutral or disagree |
75% (805) |
1.0 |
< 0.001 |
53% (591) |
1.0 |
0.001 |
|||||||||
|
Agree |
59% (278) |
0.48 (0.37–0.63) |
41% (202) |
0.68 (0.55–0.86) |
|||||||||||
|
Smoking calms you down when you are stressed or upset |
|||||||||||||||
|
Neutral or disagree |
70% (203) |
1.0 |
0.75 |
46% (140) |
1.0 |
0.09 |
|||||||||
|
Agree |
70% (880) |
1.06 (0.75–1.51) |
50% (653) |
1.28 (0.97–1.69) |
|||||||||||
|
|
|||||||||||||||
|
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. |
|||||||||||||||
3 Attitudes towards smoking and quitting among recent quitters in a national sample of Aboriginal and Torres Strait Islander people*
|
Survey question and response |
% (frequency)† |
||||||||||||||
|
|
|||||||||||||||
|
Since you quit you have more money |
|||||||||||||||
|
Strongly agree or agree |
87% (68) |
||||||||||||||
|
Neither agree or disagree (or don’t know) |
8% (6) |
||||||||||||||
|
Disagree or strongly disagree |
5% (4) |
||||||||||||||
|
You can now cope with stress as well as you did when you were smoking |
|||||||||||||||
|
Strongly agree or agree |
74% (57) |
||||||||||||||
|
Neither agree or disagree (or don’t know) |
12% (9) |
||||||||||||||
|
Disagree or strongly disagree |
14% (11) |
||||||||||||||
|
Your life is better now that you no longer smoke |
|||||||||||||||
|
Strongly agree or agree |
90% (70) |
||||||||||||||
|
Neither agree or disagree (or don’t know) |
8% (6) |
||||||||||||||
|
Disagree or strongly disagree |
3% (2) |
||||||||||||||
|
|
|||||||||||||||
|
* Results for the baseline sample of Aboriginal and Torres Strait Islander ex-smokers who had quit within past ≤ 12 months (n = 78) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses. |
|||||||||||||||
Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people
Fifty years since the United States Surgeon General’s first report on smoking and health, smoking prevalence has reduced globally,1 in part due to increased public awareness that smoking causes death and disease.2,3 However, it is possible that gaps in knowledge are contributing to health inequalities.4,5 In Australia, the prevalence of daily smoking has declined to just over 16% among adults but is higher in disadvantaged populations.6 Among the Aboriginal and Torres Strait Islander population, 42% of people aged 15 years or older smoked daily in 2012–2013.7 Understanding and tackling the causes of this disparity is a public health priority accepted by all Australian governments.8
Communicating information about the harmful effects of tobacco use is a major focus of programs to reduce smoking among Aboriginal and Torres Strait Islander peoples.9 Some evidence suggests that most Aboriginal and Torres Strait Islander people know that smoking causes lung cancer and heart disease,10–12 and that second-hand smoke (SHS) is dangerous.13–15 However, there is no current national research that describes knowledge of the harms of smoking and SHS exposure among Aboriginal and Torres Strait Islander smokers, or how it varies across this diverse population. Further, the extent to which lack of smoking-related knowledge contributes to the high smoking prevalence is unknown.
Greater knowledge and worry about future health effects of smoking have been shown to increase quit intentions and attempts in other settings.16–18 However, decisions to quit smoking are not one-dimensional, rational choices,19,20 and they may be obstructed by beliefs that diminish the likelihood or severity of smoking harms (risk minimisation).21,22 There has been some investigation into risk-minimising beliefs in Aboriginal and Torres Strait Islander tobacco control research. For example, perceived risk and worry may be low where there is discordance between information about the health consequences of smoking and the individual’s lived experience,14,23 or where there are fatalistic views of health effects that are perceived to be outside an individual’s control.12,24 This may explain why smoking persists in some contexts where knowledge of health effects is found to be high.
This is the first broadly representative description of smoking-related knowledge and health risk beliefs of Aboriginal peoples and Torres Strait Islanders. We also look at how this knowledge varies among smokers, and whether knowledge and health risk beliefs are related to quitting.
Methods
Survey design and participants
The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people (1643 current smokers, 311 ex-smokers and 568 never-smokers) from April 2012 to October 2013 (Wave 1, or baseline), and is described in detail elsewhere in this supplement.25,26 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 samples of 50 smokers (or ex-smokers who had quit ≤ 12 months before) and 25 non-smokers (never-smokers and ex-smokers who had quit > 12 months previously), with equal numbers of men and women and those aged 18–34 years and 35 years or older. The sample sizes were doubled in four major urban sites and in the Torres Strait community. People were excluded if they were: not Indigenous, not aged 18 years or older, not usual residents of the area, staff members of the ACCHS, or 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. 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 also 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.25
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, generally took 30–60 minutes to complete. A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed for each site. The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees (Appendix 1).25
Survey questions
As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), survey questions were based on ITC Project surveys previously used in Australia and New Zealand (http://www.itcproject.org/surveys). The exact questions used for this article are listed in Appendix 2.
Knowledge and health risk beliefs
Four questions assessed knowledge of the direct health effects of smoking among smokers and non-smokers — whether it causes lung cancer, causes heart disease, makes diabetes worse and causes low birthweight (answer options: “yes”, “no” or “don’t know”). Three questions assessed knowledge of the effects of SHS exposure — whether it causes asthma in children (“yes”, “no” or “don’t know”) and whether it is dangerous to non-smokers and to children (both assessed on a five-point scale from “strongly agree” to “strongly disagree”). We also computed two summary items, for correct responses to all four direct effects questions (“yes” to all) and correct responses to all three SHS measures (“yes” or at least “agree”).
Two items assessed health risk beliefs among smokers. Smokers who responded “agree” or “strongly agree” to the statement that “Smoking is not very risky when you think about all the things that people do” (assessed on a five-point scale from “strongly agree” to “strongly disagree”) were assessed as holding risk-minimising beliefs. Those who responded “very worried” to the question “How worried are you that smoking will damage your health in the future?” (assessed on a four-point scale from “not at all worried” to “very worried”) were assessed as having health worry.
Wanting and attempting to quit
Two quit-related outcomes were used: wanting to quit (“yes” or “no”) and having attempted to quit in the past year (“yes” or “no”), which was derived from questions on ever having tried to quit and timing of the most recent quit attempt.
Statistical analyses
Percentages and frequencies were calculated for all knowledge and health risk belief questions. Logistic regression was used to assess: (i) variation in correct responses among smokers, by daily smoking status, key sociodemographic variables, and presence of tobacco control resources at the local health service; and (ii) the association of knowledge and health risk beliefs with quitting interest and activity among smokers. 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.27 Both unadjusted and adjusted logistic regression analyses were performed, with daily smoking status and key sociodemographic variables included as covariates in the adjusted analyses. As unadjusted and adjusted calculations were very similar, only adjusted odds ratios (ORs) are reported here, with 95% confidence intervals.
Less than 1.5% of responses to each question were excluded (due to missing or refused responses), with the exception of quitting outcomes, which excluded a further 79 participants (4.8%) who did not know if they wanted to quit and 21 (1.3%) who did not know whether they had attempted to quit within the past year.
Results
Knowledge and health risk beliefs
Knowledge that smoking causes lung cancer and heart disease was high, and consistently over 90% of smokers and non-smokers knew about the harmful effects of SHS (Box 1). Knowledge that smoking makes diabetes worse was the lowest of all four direct effects, with 24% of daily smokers responding “don’t know” to this question (compared with 13% for low birthweight, 7% for heart disease and 3% for lung cancer). Among daily smokers, 44% held risk-minimising beliefs and 36% had health worry. Non-daily smokers had higher levels of risk-minimising beliefs and lower levels of health worry than did daily smokers.
Compared with daily smokers, non-daily smokers were more likely to respond correctly to all questions about the direct effects of smoking (OR, 1.79; 95% CI, 1.32–2.43; P < 0.001) and the harms of SHS (OR, 1.69; 95% CI, 1.08–2.62; P = 0.02) (Appendix 3).
There was some social patterning based on sociodemographic variables (Appendix 3). While knowledge of direct effects was significantly associated with employment and education, only area-level indicators were associated with both direct effects and SHS knowledge. Smokers were more likely to respond correctly to all questions if they were from a remote or very remote area (direct effects OR, 1.73; 95% CI, 1.16–2.57; SHS OR, 2.69; 95% CI, 1.61–4.52), compared with those from major cities, and smokers from an area of the highest level of disadvantage were more likely to respond correctly (direct effects OR, 1.83; 95% CI, 1.32–2.54; SHS OR, 1.33; 95% CI, 0.85–2.08) than were those from areas of least disadvantage.
Conversely, smokers from areas where the local health service had dedicated tobacco control staff or funding were less likely to respond correctly to all direct effects questions (OR, 0.64; 95% CI, 0.48–0.86) and all questions about the harms of SHS (OR, 0.58; 95% CI, 0.40–0.82), compared with those from areas where there were no dedicated resources (Appendix 3).
Relationship of knowledge and health risk beliefs with quitting
Smokers who responded correctly to all questions about harms of SHS were more likely to want to quit and to have attempted to quit in the past year, but those who responded correctly to questions about direct effects of smoking were not (Box 2). Similarly, smokers who responded correctly to all SHS knowledge questions were more likely to be very worried about their future health (OR, 4.74; 95% CI, 3.01–7.45; P < 0.001), but those with knowledge of all direct effects were not (Appendix 4). Those who were very worried about their health were more likely to want to quit and to have made a quit attempt in the past year (Box 2). Risk-minimising beliefs were not significantly associated with either wanting to quit or having attempted to quit in the past year.
Discussion
Our results show high levels of knowledge among Aboriginal and Torres Strait Islander people that smoking causes lung cancer and heart disease, along with strong awareness of the harms of SHS, consistent with previous tobacco control research in this population.10–14 Knowledge that smoking causes lung cancer and heart disease and is dangerous to others was assessed at very similar levels among Aboriginal and Torres Strait Islander daily smokers and those in the general population, based on comparable measures last assessed by Australian ITC Project surveys from 2002 to 2004.16,28
The main gap in knowledge, which has also been reported elsewhere,12 concerned the role of smoking in exacerbating diabetes. As Aboriginal and Torres Strait Islander people are more than three times as likely as non-Indigenous Australians to report a diagnosis of diabetes or high blood or urine sugar levels,7 with diabetes prevalence estimates ranging from 3.5% to 33.1%,29 this gap highlights the need for targeted education about the link between smoking and diabetes. This applies to clinicians as well as the broader Aboriginal and Torres Strait Islander population, particularly in light of updated evidence presented in the 2014 report of the US Surgeon General, which concludes that smoking increases the risk of developing type 2 diabetes in a clear dose–response manner.2
Our results also show a need to build knowledge that smoking causes low birthweight, which was either denied or not known by 18% of daily smokers, similar to previous findings.14,30 Messages that smoking causes lung cancer and heart disease and is dangerous to children have all featured on cigarette pack warning labels.31 Together with other sources of health information, such as mass media, news stories, local health promotion strategies and advice from health professionals, these are likely to have contributed to the high knowledge about these health effects among our Aboriginal and Torres Strait Islander participants.
Given health services are an important source of health information, it was surprising that knowledge was lower among smokers surveyed by sites with dedicated tobacco control resources. Though difficult to explain, this may be an indirect effect of the prioritisation of limited tobacco control resources to areas of greatest need, particularly as these resources included federally funded positions that had not long been established.9 Alternatively, it may suggest that information about the health effects of smoking is more effective when incorporated into established routine health service activities that include other areas of health and wellbeing.
Our findings suggest that gaps in knowledge are not responsible for the high prevalence of smoking or the social patterning of smoking among Aboriginal and Torres Strait Islander people. Contrary to the geographic and social patterning of smoking prevalence among Aboriginal and Torres Strait Islander people,7,32 we found that those from more remote and disadvantaged areas were more knowledgeable about the harmful effects of smoking and SHS. This is not to say that increasing knowledge is not important; prospective analyses from other ITC Project studies consistently show that knowledge, worry and risk beliefs contribute to motivation to quit.16,18,22,33 Though we have shown that knowledge is also related to interest in quitting among Aboriginal and Torres Strait Islander smokers, other factors are likely to be more important in influencing the success of quit attempts (and their translation to reduced prevalence), as found in other populations.17 For example, stress is commonly cited by Aboriginal and Torres Strait Islander smokers as a trigger for relapse,12,15,34,35 and it should be considered among other possible barriers including social normalisation of smoking, underlying social disadvantage, nicotine dependence and access to and uptake of services to support quitting.36
Among smokers, knowledge of SHS harms was associated with wanting to quit and attempts to quit, but knowing about direct, personal health consequences was not. Similarly, in an ITC Project survey in New Zealand, setting an example to children was more likely to be identified by Maori and Pacific peoples as a reason to quit, and was associated with SHS awareness and protective behaviour among smokers.37 Our findings are also consistent with qualitative research from the Northern Territory,15,24 in which Aboriginal participants expressed higher levels of concern for the health of others than for personal risk. Health is considered by many Aboriginal and Torres Strait Islander people to include the health of others.38 This may also explain why risk-minimising beliefs did not reduce interest in quitting, as predicted from research in the general population, despite being held at similar levels.21,22 It may be that these counterarguments are an ineffective shield to risks that include the health of others, and so have little or no effect on interest in quitting among Aboriginal and Torres Strait Islander people.
Our findings weaken the argument that risk-minimising beliefs explain why smoking persists in contexts where knowledge is high, and provide evidence that challenging these beliefs is unlikely to increase interest in quitting among Aboriginal and Torres Strait Islander people. Rather, health information may be interpreted with greater priority and relevance where negative health effects are framed in ways that include the health of others. This supports the approach used in the “Break the Chain” campaign, Australia’s first national Aboriginal and Torres Strait Islander antismoking campaign, launched in March 2011.39
Strengths and limitations
This is the first broadly representative survey of knowledge and health risk beliefs about smoking among Aboriginal and Torres Strait Islander peoples. The survey design made it feasible to interview a large number of people and to explore variation within our sample.
However, use of closed-ended questions may have led to overestimation of knowledge,40,41 which was assessed for a limited number of general health consequences of smoking. Knowledge may also have been overestimated if participants responded “yes” without fully scrutinising each question or because they did not want to appear uninformed. However, variation in the proportion of respondents who showed uncertainty in response to each item is evidence against this being systematic. Repeating the analyses with the “no” response as the dependent variable found the same general pattern of results (reversed). This increased our confidence in the validity of these outcomes, but did show that respondents from the most remote and disadvantaged areas were less likely to respond “don’t know”, consistent with biases to acquiesce or provide socially desirable responses in these areas. Some of the differences found, particularly area-level ones, may be due to social desirability biases, which are thought to be moderated by culture.42 Although face-to-face interviews can increase perceived pressure to provide socially acceptable responses, we attempted to reduce any such effects by engaging local interviewers, to minimise the social distance between the interviewer and participant.42
The questions used to assess health worry and risk minimisation showed good face validity, but have not been previously used to investigate these constructs with Aboriginal and Torres Strait Islander people. While these results paint a broad, representative picture of general health knowledge, concern and influence on quitting among Aboriginal and Torres Strait Islander people, more detailed assessments of knowledge may identify other gaps to target in future health information campaigns.
In conclusion, this national study found that lack of basic knowledge about the health consequences of smoking is not an important barrier to wanting and attempting to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages in ways that encompass the health of others is likely to contribute to goal setting and prioritisation of quitting.
1 Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander peoples*
|
Survey question and response |
Daily smokers (n = 1392) |
Non-daily smokers (n = 251) |
Ex-smokers (n = 311) |
Never-smokers (n = 568) |
|||||||||||
|
|
|||||||||||||||
|
Knowledge of direct health effects of smoking |
|||||||||||||||
|
Does smoking cause lung cancer? |
|||||||||||||||
|
Yes |
94% (1305) |
96% (242) |
96% (298) |
99% (560) |
|||||||||||
|
No |
2% (34) |
1% (3) |
2% (5) |
1% (4) |
|||||||||||
|
Don’t know |
3% (45) |
2% (6) |
2% (7) |
1% (4) |
|||||||||||
|
Does smoking cause heart disease? |
|||||||||||||||
|
Yes |
89% (1234) |
92% (231) |
92% (286) |
93% (526) |
|||||||||||
|
No |
4% (50) |
2% (6) |
4% (11) |
2% (13) |
|||||||||||
|
Don’t know |
7% (101) |
6% (14) |
4% (13) |
5% (29) |
|||||||||||
|
Does smoking make diabetes worse? |
|||||||||||||||
|
Yes |
68% (945) |
78% (197) |
71% (220) |
77% (435) |
|||||||||||
|
No |
7% (102) |
6% (15) |
5% (16) |
5% (28) |
|||||||||||
|
Don’t know |
24% (338) |
16% (39) |
24% (74) |
18% (105) |
|||||||||||
|
Does smoking cause low birthweight? |
|||||||||||||||
|
Yes |
82% (1131) |
87% (218) |
84% (261) |
88% (499) |
|||||||||||
|
No |
5% (75) |
3% (7) |
5% (15) |
2% (9) |
|||||||||||
|
Don’t know |
13% (179) |
10% (25) |
11% (33) |
11% (60) |
|||||||||||
|
Correct response to all four questions on direct effects of smoking |
59% (822) |
72% (181) |
61% (190) |
71% (403) |
|||||||||||
|
Knowledge of health effects of second-hand smoke |
|||||||||||||||
|
Does smoking cause asthma in children from second-hand smoke? |
|||||||||||||||
|
Yes |
91% (1265) |
94% (235) |
95% (293) |
94% (535) |
|||||||||||
|
No |
3% (38) |
2% (6) |
2% (7) |
1% (6) |
|||||||||||
|
Don’t know |
6% (82) |
4% (10) |
3% (10) |
5% (27) |
|||||||||||
|
Cigarette smoke is dangerous to non-smokers |
|||||||||||||||
|
Agree or strongly agree |
90% (1251) |
95% (238) |
95% (295) |
96% (546) |
|||||||||||
|
Neutral or don’t know |
7% (92) |
3% (7) |
2% (7) |
2% (14) |
|||||||||||
|
Disagree or strongly disagree |
3% (40) |
2% (6) |
2% (7) |
1% (8) |
|||||||||||
|
Cigarette smoke is dangerous to children |
|||||||||||||||
|
Agree or strongly agree |
95% (1317) |
98% (245) |
99% (306) |
99% (560) |
|||||||||||
|
Neutral or don’t know |
4% (52) |
2% (4) |
1% (2) |
1% (6) |
|||||||||||
|
Disagree or strongly disagree |
1% (14) |
1% (2) |
0 (1) |
0 (2) |
|||||||||||
|
Correct response to all three questions on harms of second-hand smoke |
85% (1173) |
90% (227) |
91% (282) |
91% (518) |
|||||||||||
|
Health risk beliefs |
|||||||||||||||
|
Smoking is not very risky when you think about all the things that people do |
|||||||||||||||
|
Agree or strongly agree |
44% (605) |
50% (126) |
— |
— |
|||||||||||
|
Neutral or don’t know |
18% (243) |
16% (39) |
— |
— |
|||||||||||
|
Disagree or strongly disagree |
39% (535) |
34% (86) |
— |
— |
|||||||||||
|
How worried are you that smoking will damage your health in the future? |
|||||||||||||||
|
Very worried |
36% (498) |
27% (68) |
— |
— |
|||||||||||
|
A little or moderately worried |
54% (735) |
63% (156) |
— |
— |
|||||||||||
|
Not at all worried |
10% (138) |
10% (24) |
— |
— |
|||||||||||
|
|
|||||||||||||||
|
* Results are based on the baseline sample (n = 2522) of the Talking About The Smokes project and are presented as % (frequency). Refused responses are excluded. |
|||||||||||||||
2 Association of knowledge and health risk beliefs 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 |
||||||||||||||
|
Knowledge and health risk beliefs |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
|||||||||
|
|
|||||||||||||||
|
Knowledge about direct effects of smoking |
|||||||||||||||
|
Fewer than all four questions correct |
66% (395) |
1.0 |
0.16 |
50% (312) |
1.0 |
0.67 |
|||||||||
|
All four questions correct |
72% (686) |
1.21 (0.93–1.57) |
49% (482) |
0.95 (0.77–1.18) |
|||||||||||
|
Knowledge about harms of second-hand smoke |
|||||||||||||||
|
Fewer than all three questions correct |
46% (101) |
1.0 |
< 0.001 |
36% (83) |
< 0.001 |
||||||||||
|
All three questions correct |
74% (981) |
3.26 (2.25–4.70) |
52% (710) |
1.89 (1.38–2.57) |
|||||||||||
|
Risk-minimising beliefs |
|||||||||||||||
|
Don’t know or disagree (neutral) |
72% (622) |
1.0 |
0.21 |
50% (440) |
1.0 |
0.79 |
|||||||||
|
Agree |
67% (461) |
0.83 (0.62–1.11) |
49% (353) |
0.97 (0.78–1.21) |
|||||||||||
|
Health worry |
|||||||||||||||
|
Not at all or moderately worried |
59% (576) |
1.0 |
< 0.001 |
43% (450) |
1.0 |
< 0.001 |
|||||||||
|
Very worried |
90% (500) |
6.17 (4.40–8.66) |
60% (338) |
2.14 (1.68–2.73) |
|||||||||||
|
|
|||||||||||||||
|
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 (with the exception of knowledge questions, where “don’t know” is coded as incorrect). ‡ 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. |
|||||||||||||||
Dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers
In 1988, the United States Surgeon General concluded that nicotine is the drug in tobacco that causes dependence on smoking.1 The nicotine that is delivered to the brain when smoking interacts with the habits and sensory stimuli associated with smoking to reinforce the behaviour.2 Genetic factors also influence the biological processes of nicotine delivery, metabolism and dependence.2
Clinicians and scientists have sought indicators to predict the success or failure of quit attempts, beyond indicators of motivation. The best such measure is the Heaviness of Smoking Index (HSI),3 or at least one of its two component items: cigarettes per day (CPD) and the time to first cigarette (TTFC) after waking.4,5 These two items are a subset of the six items in the Fagerström Test for Nicotine Dependence.6 There is also evidence that strong cravings (both before and after quitting) and shorter periods of abstinence on past attempts may independently predict failure of quit attempts.7–9 Identifying smokers who are most likely to have difficulty quitting is important in determining who might benefit from medications to assist cessation.
The age-standardised prevalence of smoking is 2.6 times higher among Aboriginal and Torres Strait Islander people as among other Australians.10 While both smoking prevalence and smoking intensity (based on self-reported CPD) are falling among the Aboriginal and Torres Strait Islander population, measures of dependence may differently predict which smokers will have the most difficulty quitting in this high-prevalence population where smoking is more normalised.10,11 Two small research reports have suggested that over-reliance on strategies that use stop-smoking medications may not be appropriate in this population, as nicotine dependence may be lower than in other populations.12,13 One of these studies found only low per capita consumption of cigarettes in remote Aboriginal communities,12 and the other found that only a small proportion of a sample of pregnant Aboriginal and Torres Strait Islander women who smoked were highly dependent.13
Here, we use a large national study of Aboriginal and Torres Strait Islander smokers to examine different indicators of dependence in this population and their association with sustained quit attempts, and to make comparisons with a national sample of Australian smokers.
Methods
The Talking About The Smokes (TATS) project surveyed 1392 Aboriginal and Torres Strait Islander daily smokers using a quota sampling design in the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait, and has been described elsewhere.14,15 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 ex-smokers who had quit ≤ 12 months before, and 25 non-smokers, with equal numbers of women and men and of those aged 18–34 and ≥ 35 years. In four major-city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged less than 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. The baseline sample closely matched the national 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.14
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.16 TATS project results were compared with those for 1010 daily smokers surveyed in Wave 8.5 of the Australian ITC Project between September 2011 and February 2012. That survey was completed by random digit telephone dialling or on the internet, and included smokers contacted for the first time and those who were recontacted after completing surveys in previous waves.
We asked questions about daily smokers’ usual smoking behaviour and variations in tobacco consumption, how easy it would be to not smoke, difficulties during their most recent quit attempt (eg, strong cravings, being around others who smoke), the duration of their longest quit attempt (to assess if any attempt had been sustained for at least 1 month) and sociodemographic factors. The questions are described in detail in Appendix 1.
The HSI was coded 0 to 6 based on the sum of the responses to the two questions about CPD and TTFC. These items were each coded as 0 (0–10 CPD; TTFC, ≥ 61 min), 1 (11–20 CPD; TTFC, 31–60 min), 2 (21–30 CPD; TTFC, 6–30 min) or 3 (≥ 31 CPD; TTFC, ≤ 5 min).3 We categorised HSI as low (0–1), moderate (2–3) or high (4–6).17,18 We also assessed the three criteria for dependence given in the Royal Australian College of General Practitioners (RACGP) cessation guidelines: TTFC ≤ 30 min, > 10 CPD, and withdrawal symptoms on previous quit attempts (defined in our sample as strong cravings during the most recent quit attempt).2
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. Therefore, we could not assess the statistical significance of differences with the Australian ITC Project results. The results for daily smokers in the Australian ITC Project 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 sociodemographic variables and HSI using χ2 tests 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 We assessed the association between indicators of dependence and sustained quit attempts using simple logistic regression, with confidence intervals adjusted for the sampling design and P values calculated for each variable using adjusted Wald tests.
Reported percentages and frequencies exclude those refusing to answer, answering “don’t know”, or for whom the question was not applicable (eg, questions about the most recent quit attempt excluded those who had not made an attempt in the past 5 years). Less than 2% of daily smokers answered “don’t know” or refused to answer each of the questions analysed here, except that 18 smokers (2.0%) answered “don’t know” to the question about difficulty in saying no when offered a cigarette during their most recent quit attempt, and 32 (2.3%) refused to answer the question about being unable to afford to buy cigarettes.
Results
There was little difference in the mean HSI scores for daily smokers in the TATS project compared with those in the Australian ITC Project (2.62 v 2.64; 95% CI, 2.45–2.83), but the TATS sample had fewer low and high scores and more moderate scores (Box 1). A higher proportion of smokers in the TATS project smoked 10 or fewer cigarettes per day (40% v 33.4%), but more also smoked their first cigarette within 30 minutes of waking (75% v 64.6%; 95% CI, 58.8%–70.0%). Lower proportions of Aboriginal and Torres Strait Islander smokers reported having strong urges to smoke at least several times a day (51% v 60.7%) or that it would be very hard to quit (39% v 47.9%).
Within the TATS sample, older smokers were more likely to have higher HSI scores, as were smokers who were not in the labour force, those with less education, those from both the most and least disadvantaged areas, and Aboriginal smokers compared with Torres Strait Islander smokers (Box 2).
Box 3 presents the results for questions that were only asked in the TATS project. Nearly half the smokers (47%) reported finding it very or extremely hard to go without smoking for a whole day, and most reported experiencing difficulties during their most recent quit attempt. A quarter (24%) of daily smokers had all three of the RACGP indicators of dependence.
Among the 61% of smokers in the TATS sample (833/1371) who had made a quit attempt in the past 5 years, all the indicators of dependence, except CPD and strong urges, were associated with being less likely to have made a sustained quit attempt of at least 1 month (Box 4). The indicators with the strongest negative associations with making a sustained quit attempt were the smokers’ assessments of how hard it would be to quit and their difficulties during the most recent quit attempt. Although the HSI and the RACGP criteria of dependence were negatively predictive of making a sustained quit attempt, CPD — one of their component measures — was not.
Nearly half the daily smokers in the TATS sample (45%, 606/1354) reported being unable to buy cigarettes for at least a few days in each fortnight before pay day, and 23% (314/1354) less often, while for 32% (435/1354) this was never a problem. When smokers were unable to buy them, 37% (342/916) reported they were often or very often given cigarettes, and 50% (460/916) were sometimes given them. As a result, 27% (245/911) said they smoked the same amount as usual when unable to buy cigarettes, while 50% (456/911) smoked a bit less and only 23% (210/911) smoked a lot less or not at all.
Compared with Australian smokers in the ITC Project, fewer Aboriginal and Torres Strait Islander smokers in the TATS project reported that the amount they smoked varied from day to day (42% [580/1392] v 58.5% [95% CI, 53.1%–63.7%]), but more reported that spending money on cigarettes left them with insufficient money for food or other essentials (23% [321/1378] v 12.9% [95% CI, 8.7%–18.6%]).
The Aboriginal and Torres Strait Islander smokers whose smoking led to insufficient money for essentials were less likely to have made sustained attempts to quit (odds ratio [OR], 0.70; 95% CI, 0.37–0.71; P < 0.001). Smokers who were never unable to afford cigarettes were less likely to have made a sustained quit attempt than those who were sometimes unable to buy them (OR, 0.51; 95% CI, 0.37–0.71; P < 0.001). Those who said they smoked about the same as usual when they were unable to buy cigarettes were also less likely to have made a sustained quit attempt, compared with those who at such times smoked a lot less or not at all (OR, 0.61; 95% CI, 0.41–0.91; P = 0.01).
Discussion
We found mixed relationships between indicators for dependence and sustained quit attempts in our sample of Aboriginal and Torres Strait Islander smokers. Based on CPD, frequency of strong urges to smoke and perceptions of how hard it would be to quit, dependence in this population appeared lower than among all Australian smokers. In contrast, our sample had a shorter TTFC. Nevertheless, the associations we found between dependence, as measured by the HSI, and being older and socially disadvantaged were similar to those in previous cross-sectional Australian ITC Project research.20
Previous research suggests TTFC is a more useful measure of dependence and a better predictor of successful quitting than CPD, although both are predictive and may contribute independently.4,5,21,22 Consistent with this, we found that longer TTFC was associated with having made a sustained quit attempt, while CPD was not. However, we also found no association for the frequency of strong urges while still smoking, which has been shown to be associated with successful quitting in longitudinal research, performing better than the Fagerström Test for Nicotine Dependence or its components, HSI, TTFC or CPD.7,8 These findings question the utility of existing indicators of dependence to predict successful quitting in Aboriginal and Torres Strait Islander smokers.
Aboriginal and Torres Strait Islander smokers’ perceptions of greater ease in quitting (quitting self-efficacy) may be falsely optimistic, perhaps reflecting less experience of unsuccessful quit attempts.23 In 2012–2013, only 37% of Aboriginal and Torres Strait Islander adults who had ever smoked had successfully quit, compared with 63% of other Australians.10 Some of the cross-sectional association we found between quitting self-efficacy and sustained quit attempts is likely to be in the reverse direction, with those who have not been able to sustain quit attempts understandably reporting that quitting will be harder. However, in other longitudinal research of the ITC Project, quitting self-efficacy has been associated with preventing relapses, both before and after a month.7 Nevertheless, we can take advantage of this optimism to encourage quit attempts.
Most Aboriginal and Torres Strait Islander smokers reported withdrawal symptoms (cravings) and situational difficulties during their most recent quit attempt, which have been described in more detail in previous qualitative research.24 It is notable that questions about the most recent quit attempt were consistently stronger predictors of being unable to sustain quit attempts than were traditional measures of dependence based on typical daily smoking patterns. Our results are consistent with more detailed recent research in other settings, which suggested that the components of the HSI are only predictive of early relapses in the first weeks of a quit attempt, whereas cravings and situational cues (such as the number of close friends who smoke) are important after 1 month.7,25
Current clinical guidelines recommend that clinicians ask smokers not only about CPD and TTFC, but also about their past unsuccessful quit attempts.26,27 Beyond emphasising the utility of the existing question about difficulties experienced during past attempts, we recommend waiting for further research on how the different measures prospectively predict quitting success before suggesting changes to the guidelines for Aboriginal and Torres Strait Islander smokers.
It is possible that estimates of CPD might be less accurate among Aboriginal and Torres Strait Islander smokers, where the relationship between purchase and consumption is more complicated because sharing and being unable to buy cigarettes are common. Two small studies of Aboriginal and Torres Strait Islander people showed that self-reported CPD is associated with urinary cotinine levels, but did not discuss whether the association was similar to that in other populations.28,29 However, we found that Aboriginal and Torres Strait Islander smokers were less likely than all Australian smokers to report variation in the number of cigarettes smoked each day, so it is difficult to suggest that such day-to-day variations are the reason for CPD being less useful in this setting. Those who managed to maintain usual consumption levels when they were unable to buy cigarettes were less likely to have sustained a quit attempt than those who smoked less at these times. Sharing of cigarettes therefore seems to increase in response to the inability to buy cigarettes among more dependent smokers, as has been reported elsewhere in response to pay cycles and the increased cost of cigarettes after tobacco excise rises.24,30
Strengths and limitations
The main strength of our study is its large national sample of Aboriginal and Torres Strait Islander smokers, providing detailed information about dependence directly from a population with a high prevalence of smoking. However, it is a non-random, albeit broadly representative, sample and caution is needed in making comparisons with the Australian ITC Project sample.
The cross-sectional associations we found warrant confirmation from future longitudinal analyses. There may have been some reverse causation, with past experiences of sustaining or not sustaining quit attempts influencing answers to the questions about dependence. Further, sustained attempts may have occurred years earlier, and the smokers’ dependence may have since changed. The use of past sustained quit attempts as an outcome necessarily meant excluding those who had not made any attempts. Predicting future quitting in this subgroup will be important but cannot include measures based on non-existent past attempts.
Our self-reported data are probably limited by incomplete recall of past quit attempts, and both forgetting and misremembering of symptoms. The effect of most of these biases will be to weaken reported associations, leading to greater confidence in the significant associations but requiring caution in the implications of findings of no association. For example, the lack of association of strong urges to smoke with sustained quitting found here, in contrast to other research, requires further exploration.8 More Aboriginal smokers than other Australian smokers use roll-your-own cigarettes, which may have caused greater misclassification bias of estimates of CPD.31 Future longitudinal analyses of the predictive association of these dependence measures with relapses and successful quitting should also control for the moderating effect of stop-smoking medication, which we were not able to do.25
1 Comparison of indicators of nicotine dependence among Aboriginal and Torres Strait Islander daily smokers and those in the Australian population*
|
Indicator of dependence |
Talking About The Smokes project, % (frequency)† |
Australian ITC Project, |
|||||||||||||
|
|
|||||||||||||||
|
Cigarettes per day |
|||||||||||||||
|
1–10 |
40% (547) |
33.4% (27.9%–39.3%) |
|||||||||||||
|
11–20 |
39% (528) |
42.2% (36.8%–47.7%) |
|||||||||||||
|
21–30 |
18% (242) |
18.5% (14.7%–22.9%) |
|||||||||||||
|
≥ 31 |
4% (54) |
6.0% (3.7%–9.6%) |
|||||||||||||
|
Time to first cigarette |
|||||||||||||||
|
More than 60 minutes |
9% (125) |
16.1% (11.9%–21.3%) |
|||||||||||||
|
31–60 minutes |
16% (220) |
19.4% (15.3%–24.2%) |
|||||||||||||
|
6–30 minutes |
64% (884) |
46.7% (41.2%–52.3%) |
|||||||||||||
|
5 minutes or less |
11% (145) |
17.9% (13.6%–23.2%) |
|||||||||||||
|
Heaviness of Smoking Index (HSI) score |
|||||||||||||||
|
Low (0–1) |
17% (234) |
24.5% (19.5%–30.3%) |
|||||||||||||
|
Moderate (2–3) |
59% (796) |
44.6% (39.2%–50.1%) |
|||||||||||||
|
Heavy (4–6) |
24% (328) |
30.9% (25.8%–36.5%) |
|||||||||||||
|
How often do you get strong urges to smoke? |
|||||||||||||||
|
Never or less than daily |
21% (291) |
12.4% (9.0%–16.9%) |
|||||||||||||
|
Daily |
27% (375) |
26.9% (21.9%–32.5%) |
|||||||||||||
|
Several times a day or more often |
51% (706) |
60.7% (54.9%–66.2%) |
|||||||||||||
|
How easy or hard would it be for you to quit? |
|||||||||||||||
|
Very or somewhat easy |
17% (234) |
10.4% (6.9%–15.4%) |
|||||||||||||
|
Neither easy nor hard |
11% (156) |
7.9% (5.0%–12.2%) |
|||||||||||||
|
A little bit hard |
32% (439) |
33.7% (28.8%–39.0%) |
|||||||||||||
|
Very hard |
39% (537) |
47.9% (42.3%–53.6%) |
|||||||||||||
|
|
|||||||||||||||
|
ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses and “don’t know” responses. † Results are for Aboriginal and Torres Strait Islander daily smokers (n = 1392) in the baseline sample of the Talking About The Smokes project (April 2012 – October 2013). ‡ Results are for daily smokers (n = 1010) in the Australian population from Wave 8.5 of the Australian ITC Project (September 2011 – February 2012) and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey. |
|||||||||||||||
2 Heaviness of Smoking Index among Aboriginal and Torres Strait Islander daily smokers, by sociodemographic factors (n = 1392)*
|
Heaviness of Smoking Index score |
|||||||||||||||
|
Characteristic |
Low, % (frequency) |
Moderate, % (frequency) |
High, % (frequency) |
P† |
|||||||||||
|
|
|||||||||||||||
|
Total daily smokers |
17% (234) |
59% (796) |
24% (328) |
||||||||||||
|
Age (years) |
< 0.001 |
||||||||||||||
|
18–24 |
22% (60) |
68% (187) |
11% (29) |
||||||||||||
|
25–34 |
21% (76) |
57% (209) |
23% (84) |
||||||||||||
|
35–44 |
14% (45) |
58% (186) |
28% (92) |
||||||||||||
|
45–54 |
16% (37) |
56% (132) |
28% (67) |
||||||||||||
|
≥ 55 |
10% (16) |
53% (82) |
36% (56) |
||||||||||||
|
Sex |
0.12 |
||||||||||||||
|
Female |
19% (134) |
59% (417) |
22% (153) |
||||||||||||
|
Male |
15% (100) |
58% (379) |
27% (175) |
||||||||||||
|
Indigenous status |
0.027 |
||||||||||||||
|
Aboriginal |
16% (195) |
59% (717) |
25% (297) |
||||||||||||
|
Torres Strait Islander or both |
26% (39) |
53% (79) |
21% (31) |
||||||||||||
|
Labour force status |
< 0.001 |
||||||||||||||
|
Employed |
21% (101) |
58% (274) |
21% (97) |
||||||||||||
|
Unemployed |
18% (82) |
63% (293) |
19% (89) |
||||||||||||
|
Not in labour force |
12% (51) |
54% (227) |
34% (142) |
||||||||||||
|
Highest education attained |
0.036 |
||||||||||||||
|
Less than Year 12 |
14% (101) |
59% (411) |
27% (188) |
||||||||||||
|
Finished Year 12 |
19% (68) |
58% (204) |
23% (80) |
||||||||||||
|
Post-school qualification |
22% (63) |
59% (172) |
20% (57) |
||||||||||||
|
Treated unfairly because Indigenous in past year |
0.72 |
||||||||||||||
|
Never |
18% (106) |
57% (335) |
25% (145) |
||||||||||||
|
At least some of the time |
17% (124) |
59% (439) |
24% (176) |
||||||||||||
|
Remoteness |
0.34 |
||||||||||||||
|
Major cities |
15% (52) |
60% (214) |
25% (88) |
||||||||||||
|
Inner and outer regional |
19% (137) |
59% (420) |
22% (158) |
||||||||||||
|
Remote and very remote |
16% (45) |
56% (162) |
28% (82) |
||||||||||||
|
Area-level disadvantage |
0.027 |
||||||||||||||
|
1st quintile (most disadvantaged) |
16% (83) |
57% (290) |
27% (137) |
||||||||||||
|
2nd and 3rd quintiles |
21% (121) |
59% (342) |
21% (121) |
||||||||||||
|
4th and 5th quintiles |
11% (30) |
62% (164) |
27% (70) |
||||||||||||
|
|
|||||||||||||||
|
* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † P values were calculated using the χ2 test adjusted for sampling design. |
|||||||||||||||
3 Other indicators of nicotine dependence and difficulties during the most recent quit attempt among Aboriginal and Torres Strait Islander daily smokers
|
Indicator of dependence |
Daily smokers, % (frequency)* |
||||||||||||||
|
|
|||||||||||||||
|
All daily smokers (n) |
1392 |
||||||||||||||
|
RACGP criteria for dependence† |
|||||||||||||||
|
None |
12% (162) |
||||||||||||||
|
One |
24% (334) |
||||||||||||||
|
Two |
41% (564) |
||||||||||||||
|
All three |
24% (327) |
||||||||||||||
|
How hard is it to go without smoking for a whole day? |
|||||||||||||||
|
Not at all or somewhat hard |
47% (654) |
||||||||||||||
|
Very or extremely hard |
47% (657) |
||||||||||||||
|
Not sure or never tried |
6% (79) |
||||||||||||||
|
If tried to quit in the past 5 years (n) |
884 |
||||||||||||||
|
During last quit attempt |
|||||||||||||||
|
Had strong cravings |
70% (591) |
||||||||||||||
|
Hard to be around smokers |
72% (621) |
||||||||||||||
|
Hard to say no when offered a smoke |
67% (572) |
||||||||||||||
|
Missed the time out you get when having a smoke |
51% (430) |
||||||||||||||
|
|
|||||||||||||||
|
RACGP = Royal Australian College of General Practitioners. * Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Time to first cigarette ≤ 30 min, > 10 cigarettes per day, and withdrawal symptoms on previous quit attempts (strong cravings during most recent quit attempt). |
|||||||||||||||
4 Association of indicators of dependence with sustaining a quit attempt for at least 1 month in a national sample of Aboriginal and Torres Strait Islander daily smokers*
|
Indicator of dependence |
Sustained quit attempt, |
Odds ratio (95% CI)‡ |
P§ |
||||||||||||
|
|
|||||||||||||||
|
Total |
47% (388) |
||||||||||||||
|
Heaviness of Smoking Index score |
0.046 |
||||||||||||||
|
Low (0–1) |
50% (71) |
1.0 |
|||||||||||||
|
Moderate (2–3) |
48% (238) |
0.91 (0.66–1.26) |
|||||||||||||
|
Heavy (4–6) |
38% (68) |
0.60 (0.39–0.91) |
|||||||||||||
|
RACGP criteria for dependence |
0.001 |
||||||||||||||
|
None |
54% (38) |
1.0 |
|||||||||||||
|
One |
57% (92) |
1.12 (0.60–2.09) |
|||||||||||||
|
Two |
47% (133) |
0.73 (0.43–1.24) |
|||||||||||||
|
All three |
39% (124) |
0.55 (0.33–0.90) |
|||||||||||||
|
Cigarettes per day |
0.19 |
||||||||||||||
|
1–10 |
47% (153) |
1.0 |
|||||||||||||
|
11–20 |
48% (163) |
1.02 (0.75–1.38) |
|||||||||||||
|
21–30 |
45% (57) |
0.89 (0.58–1.37) |
|||||||||||||
|
≥ 31 |
27% (9) |
0.42 (0.18–0.94) |
|||||||||||||
|
Time to first cigarette |
0.024 |
||||||||||||||
|
More than 60 minutes |
53% (43) |
1.0 |
|||||||||||||
|
31–60 minutes |
55% (73) |
1.08 (0.57–2.03) |
|||||||||||||
|
6–30 minutes |
45% (235) |
0.72 (0.45–1.13) |
|||||||||||||
|
5 minutes or less |
36% (31) |
0.51 (0.27–0.94) |
|||||||||||||
|
How often do you get strong urges to smoke? |
0.49 |
||||||||||||||
|
Never or less than daily |
49% (90) |
1.0 |
|||||||||||||
|
Daily |
47% (109) |
0.91 (0.61–1.38) |
|||||||||||||
|
Several times a day or more often |
45% (184) |
0.82 (0.58–1.17) |
|||||||||||||
|
How hard is it to go without smoking for a whole day? |
0.01 |
||||||||||||||
|
Not at all or somewhat hard |
51% (219) |
1.0 |
|||||||||||||
|
Very or extremely hard |
42% (159) |
0.69 (0.52–0.92) |
|||||||||||||
|
Not sure or never tried |
33% (9) |
0.47 (0.22–1.05) |
|||||||||||||
|
How easy or hard would it be for you to quit? |
< 0.001 |
||||||||||||||
|
Very or somewhat easy |
61% (94) |
1.0 |
|||||||||||||
|
Neither easy nor hard |
53% (46) |
0.72 (0.42–1.25) |
|||||||||||||
|
A little bit hard |
46% (125) |
0.53 (0.36–0.78) |
|||||||||||||
|
Very hard |
38% (120) |
0.39 (0.27–0.56) |
|||||||||||||
|
During most recent quit attempt |
|||||||||||||||
|
Did you get strong cravings? |
< 0.001 |
||||||||||||||
|
No |
59% (149) |
1.0 |
|||||||||||||
|
Yes |
42% (236) |
0.49 (0.37–0.66) |
|||||||||||||
|
Was it hard to be around smokers? |
< 0.001 |
||||||||||||||
|
No |
59% (133) |
1.0 |
|||||||||||||
|
Yes |
42% (252) |
0.51 (0.38–0.69) |
|||||||||||||
|
Was it hard to say no when offered a smoke? |
< 0.001 |
||||||||||||||
|
No |
58% (154) |
1.0 |
|||||||||||||
|
Yes |
41% (225) |
0.50 (0.35–0.70) |
|||||||||||||
|
Did you miss the time out you get when having a smoke? |
0.03 |
||||||||||||||
|
No |
51% (197) |
1.0 |
|||||||||||||
|
Yes |
44% (179) |
0.74 (0.56–0.98) |
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RACGP = Royal Australian College of General Practitioners. * Results are based on daily smokers in the baseline sample of the Talking About The Smokes project who had made at least one quit attempt in the past 5 years (n = 833). † 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 for the entire variable, using adjusted Wald tests. |
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