Smoke-free homes and workplaces of a national sample of Aboriginal and Torres Strait Islander people

Second-hand smoke was estimated to cause more than 600 000 deaths globally in 2004, mainly from ischaemic heart disease, respiratory infections, asthma and lung cancer.1 Protecting people from the dangers of second-hand smoke by banning smoking in indoor and other public places is an essential element of effective tobacco control programs.2

Smoking is banned in virtually all enclosed public places in Australia.3 More than 92% of Australian smokers and ex-smokers reported that smoking was not allowed in any indoor area at their workplace in 2010–2011, slightly less than in similar surveys in the United Kingdom and Canada but more than in the United States and European and middle- and low-income countries surveyed.4 In Australia5 and all countries with available trend data, the proportion of the population living in smoke-free homes is increasing; this is not just due to falling smoking prevalence.6

Forty-two per cent of Aboriginal and Torres Strait Islander people aged 15 years or older were daily smokers in 2012–2013, 2.6 times the age-standardised prevalence among other Australians.7 This is a decrease from 45% in 2008 and 49% in 2002, a similar rate of decline as among other Australians.7 In 2008, Aboriginal and Torres Strait Islanders who smoked daily were less likely than other Australians to live in homes where no one usually smoked inside (56% v 68%).5 Aboriginal and Torres Strait Islander smokers with lower household incomes were significantly more likely to live in homes where someone usually smoked inside.5

Here, we provide the first national picture of smoking bans in the workplaces of Aboriginal and Torres Strait Islander people. We also describe whether home smoking bans were always followed and assess the associations between smoke-free workplaces and homes and quitting.

Methods

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people 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.8,9 Briefly, the 35 sites were selected based on the geographic 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 in each of two age groups (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 distribution of age, sex, jurisdiction, remoteness, quit attempts in past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). 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.8 A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed at 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.

As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), interview questions were closely based on those in other ITC Project studies, especially the Australian ITC surveys.10 We asked questions about whether smoking was allowed inside the home, and whether people smoked inside even if it was not allowed. For those with either an incomplete smoking ban or a complete ban where people still smoked inside the house, we asked if participants were uncomfortable telling elders or community leaders, other visitors or other household members to smoke outside. For participants who were employed, we asked about smoking rules in indoor areas at work. The questions used in this article are listed in Appendix 1.

Results were compared with those from the Australian ITC Project surveys conducted in September 2011 to February 2012 (Wave 8.5, n = 1504) or July 2010 to May 2011 (Wave 8, n = 1513). These surveys were completed by random digit telephone dialling or on the internet, and included those contacted for the first time and those who were recontacted after completing surveys in previous waves. Only smokers were recruited, so these samples only included smokers and ex-smokers who had quit since previous waves. 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 focused our comparisons on daily smokers.

Statistical analyses

We calculated the percentages and frequencies of responses to the TATS project questions, but did not include confidence intervals for these as it is not considered statistically acceptable to estimate sampling error in non-probabilistic samples. We compared results for daily smokers with those from Australian ITC Project surveys, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

Associations between the outcome variables and sociodemographic and smoking variables were assessed using logistic regression to generate odds ratios (ORs) and P values based on Wald tests. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, using 35 site clusters, and the age–sex quotas as strata.11

Reported percentages and frequencies exclude participants who refused to answer, answered “don’t know”, or for whom the question was not applicable (eg, not employed or no indoor area at work). Less than 1% answered “don’t know” or refused to answer each of the questions analysed in this report, except for questions about being uncomfortable telling others to smoke outside, being treated unfairly, quit attempts and wanting to quit. However, even the least completely answered of these questions, about wanting to quit, had only 79 participants (4.8%) who answered “don’t know” and 11 (0.7%) who refused to answer.

Results

Smoke-free homes

More than half of smokers (56%, 908/1628) and 80% (701/876) of non-smokers reported that smoking was never allowed anywhere in their home. Non-daily smokers (69%; OR, 1.94; 95% CI, 1.45–2.58), ex-smokers (79%; OR 3.36; 95% CI, 2.50–4.51) and never-smokers (80%; OR, 3.58; 95% CI, 2.84–4.52) were significantly more likely to report such bans than were daily smokers (53%) (Box 1). A similar age–sex-standardised percentage of Australian daily smokers (53.4%) reported total home smoking bans in Wave 8.5 of the Australian ITC Project study.

Of the smokers who reported that smoking was never allowed inside, 10% (91/903) said that some people still smoked inside regardless. So, 50% (812/1623) reported an effective total ban, and 28% (450/1623) a partial ban (including a total ban that was not fully effective), while 22% (361/1623) reported that smoking was allowed anywhere inside. Of those with a partial ban, 51% (225/442) reported being uncomfortable telling elders or community leaders (190/439; 43%), visitors (154/443; 35%) or other householders (125/442; 28%) to smoke outside. Of the respondents with no ban, 59% (213/363) reported it would be possible to stop people smoking inside, but 53% of these (114/215) reported that they would have to make some exceptions.

Smokers who were significantly more likely to report an effective total home smoking ban included non-daily smokers, employed people, Torres Strait Islanders and people who were both Torres Strait Islander and Aboriginal (v Aboriginal people), people aged 18–24 years (v those aged 45 years or over), people with children in their home, those who had finished Year 12 or had post-secondary educational qualifications (v those with less than Year 12), and those who did not feel they had been treated unfairly in the past year because they were Aboriginal or Torres Strait Islander (Box 2). There was no significant association between sex, remoteness or area-level disadvantage and having an effective ban.

Smoke-free workplaces

Most employed Aboriginal and Torres Strait Islander daily smokers (406; 88%) reported that smoking was not allowed in any indoor area at work, similar to the standardised estimate in Wave 8 of the Australian ITC Project study (88.5%) (Box 1).

Remoteness and area-level disadvantage were significantly associated with non-smokers not being protected by a workplace indoor smoking ban (Box 3). Smokers working in smoke-free workplaces were more likely to have effective smoking bans at home than those in workplaces where smoking was allowed in some or all indoor areas (287/484, 59% v 22/65, 34%; OR, 2.85; 95% CI, 1.67–4.87).

Association with quit attempts and wanting to quit

Smokers who lived in homes with an effective total smoking ban were significantly more likely than other smokers to have made a quit attempt in the past year, to want to quit and (among smokers who had attempted to quit in the past 5 years) to have made a quit attempt of 1 month or longer (Box 4). In contrast, there were no such significant associations with working in a smoke-free workplace.

Discussion

Smoke-free homes

Previous research has shown that the proportion of smokers who reported living in smoke-free homes was increasing faster among Aboriginal and Torres Strait Islanders than among other Australians, but that a gap remained in 2008.5 Our study demonstrates that this gap now appears to have been closed, reflecting a significant change in behaviour by Aboriginal and Torres Strait Islander smokers.

This does not mean that there is no gap in the proportion of households that are smoke-free or in the proportion of children who live in smoke-free households. Changes to these will probably require smoking prevalence to fall further, along with more smokers choosing to smoke outside. We found that the presence of infants, children and adult non-smokers in the household was associated with having a smoke-free home, consistent with earlier ITC Project research, including Australian surveys.12 Longitudinal research in Darwin also showed that Aboriginal households implemented smoking bans after the birth of a baby.12,13 As in previous research, we found that the most disadvantaged Aboriginal and Torres Strait Islander people were the least likely to live in smoke-free homes, although this association did not hold for remoteness or area-level disadvantage.5

It is encouraging that few people reported any lapses in maintaining their home smoking bans, and more than half of those with no ban reported that a ban would be possible. People more often reported being uncomfortable telling elders or community leaders to smoke outside, rather than other visitors or householders. Local tobacco action workers could work with elders and community leaders to find respectful solutions, so that people do not feel uncomfortable about asking them not to smoke inside. Further research into the barriers to maintaining effective home smoking bans would be useful.

A literature review suggested that comprehensive national tobacco control programs to reduce smoking prevalence are the most effective in increasing the prevalence of smoke-free homes.14 Australia has boosted comprehensive national tobacco control activity in recent years, including programs specifically for Aboriginal and Torres Strait Islander peoples.15 This has been complemented by local tobacco control activity at the participating sites. Local and regional Aboriginal and Torres Strait Islander social marketing campaigns have focused on smoke-free homes (eg, “Smoking can kill those close to you” in the Northern Territory).16 However, the evidence for the impact of such campaigns on the prevalence of smoke-free homes is more modest, as is the evidence for direct counselling of families about smoke-free homes.3,14,17

Other research has demonstrated an increase in smoke-free homes after smoking bans have been implemented in public places, and we have similarly demonstrated an association between smoke-free homes and smoke-free workplaces.4 The previously demonstrated greater concern by Aboriginal people for the effects of smoking on family, especially children, rather than on their own health, further explains the rapid spread of home smoking bans.18 Introducing a home smoking ban is easier than successfully quitting, but the significant association we found between smoke-free homes and quitting suggests that smokers are not making their homes smoke-free as a substitute to quitting.

However, this optimism needs to be tempered by research that shows reported indoor home smoking bans reduce but do not eliminate children’s exposure to environmental tobacco smoke and its toxins.19,20

Smoke-free workplaces

It is good news that almost all Aboriginal and Torres Strait Islander people reported being protected by indoor smoking bans at work, as is reported by other Australians. We are not aware of comparable data to assess trends, but there has been considerable recent attention to promoting and supporting smoke-free policies at Aboriginal organisations. Improvements can still be made in the most disadvantaged and remote areas. Better monitoring and enforcement of existing indoor smoking bans, as well as their extension to outdoor public spaces (where people are close together), is a focus of the current National Tobacco Strategy.15

Association with quit attempts and wanting to quit

Our cross-sectional study is consistent with longitudinal ITC Project research, including Australian surveys, which showed that having a total indoor home smoking ban was associated with both quit intentions and making more and longer quit attempts.12 However, a cross-sectional study using earlier Australian Bureau of Statistics (ABS) Aboriginal and Torres Strait Islander survey data found only a non-significant association with quit attempts, but did find a significant association with successful past cessation.5 Making the home smoke-free might make it easier for a smoker to quit, but it is also likely that this association is in part due to smokers who are most concerned about their smoking making their homes smoke-free as part of the quitting process.

Strengths and limitations

This is a large nationally representative (albeit not random) survey of Aboriginal and Torres Strait Islander people. However, caution is needed as it relies on self-report of smoke-free homes and workplaces without biochemical verification. Due to inaccurate recall or social desirability bias, it is likely that some participants with reportedly effective total smoking bans are still being exposed to second-hand smoke. However, we think marked bias is unlikely as smoking is still very common and normalised in these communities. Our finding that 10% of smokers reported that some smoking occurred in the home despite not being allowed suggests there was minimal bias towards the most socially desirable response (complete adherence to the smoking ban).

Our questions were the same as in the ITC Project comparison survey, but they differed from those used in ABS surveys.5 The ABS asked whether any householders usually smoke inside, whereas we asked whether smoking (by anyone) was ever allowed inside, and whether people smoked in spite of bans. Therefore, our estimates for the percentage of daily smokers living in homes where smoking was either not allowed (53%) or with effective total home smoking bans (48%) were understandably lower than the 2008 ABS estimate for those living in homes where no householder usually smoked inside (56.3%; 95% CI, 52.4%–60.2%).

Analyses of longitudinal data using follow-up surveys to this baseline survey will provide more methodologically sound confirmation of likely causal directions of the observed cross-sectional associations.

In conclusion, we found that the gap has closed between the proportion of Aboriginal and Torres Strait Islander smokers and all Australian smokers who live in homes with smoking bans, and that these bans may help smokers to quit. Aboriginal and Torres Strait Islander non-smokers are also well protected from second-hand smoke at work.

1 Smoking bans in homes and workplaces*

	Australian ITC Project†	Talking About The Smokes project
	Daily smokers, % (95% CI)	Daily smokers, % (frequency)	Non-daily smokers, % (frequency)	Ex-smokers, % (frequency)	Never-smokers, % (frequency)

Home (n)	1010	1377	251	310	568
Total smoking ban	53.4% (47.7%–59.0%)	53% (735)	69% (173)	79% (246)	80% (455)
Partial smoking ban	31.0% (25.7%–36.8%)	23% (313)	18% (46)	15% (46)	14% (80)
No ban	15.7% (11.7%–20.6%)	24% (329)	13% (32)	6% (18)	5% (31)
Work (n)	604	461	89	131	284
Total indoor ban	88.5% (80.9%–93.3%)	88% (406)	89% (79)	95% (124)	93% (263)
Partial indoor ban	4.5% (2.0%–10.0%)	6% (27)	11% (10)	2% (2)	4% (11)
No ban	7.0% (3.3%–14.3%)	6% (28)	0	4% (5)	4% (10)

ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. † Australian ITC Project results are from Wave 8.5 (home), conducted September 2011 to February 2012, and Wave 8 (work), conducted July 2010 to May 2011, and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

2 Aboriginal and Torres Strait Islander smokers with effective home smoking bans,* by sociodemographic factors (n = 1643)

Characteristic	% (frequency)†	Odds ratio (95% CI)	P‡

Total	50% (812)
Age (years)
18–24	56% (193)	1.0	< 0.001
25–34	55% (242)	0.95 (0.71–1.28)
35–44	51% (199)	0.79 (0.54–1.16)
45–54	38% (102)	0.47 (0.31–0.70)
≥ 55	43% (76)	0.58 (0.39–0.86)
Sex
Female	53% (441)	1.0	0.15
Male	47% (371)	0.81 (0.61–1.08)
Number of infants in home
None	47% (670)	1.0	< 0.001
One or more	69% (139)	2.49 (1.79–3.48)
Number of children in home
None	39% (267)	1.0	< 0.001
One or more	58% (540)	2.11 (1.68–2.65)
Indigenous status
Aboriginal	49% (699)	1.0	0.04
Torres Strait Islander or both	60% (113)	1.61 (1.03–2.52)
Labour force status
Employed	56% (318)	1.0	0.02
Unemployed	47% (260)	0.69 (0.52–0.91)
Not in labour force	47% (232)	0.70 (0.53–0.94)
Highest education attained
Less than Year 12	44% (371)	1.0	< 0.001
Finished Year 12	57% (246)	1.69 (1.30–2.21)
Post-school qualification	56% (193)	1.58 (1.16–2.15)
Treated unfairly because Indigenous in past year
No	54% (369)	1.0	0.01
Yes	47% (425)	0.75 (0.60–0.93)
Smoking status
Daily smoker	48% (660)	1.0	0.003
Non-daily smoker	61% (152)	1.68 (1.20–2.34)
Remoteness
Major cities	52% (220)	1.0	0.66
Inner and outer regional	50% (412)	0.93 (0.68–1.27)
Remote and very remote	47% (180)	0.82 (0.53–1.26)
Area-level disadvantage
1st quintile (most disadvantaged)	51% (325)	1.0	0.30
2nd and 3rd quintiles	51% (348)	1.01 (0.74–1.37)
4th and 5th quintiles	45% (139)	0.78 (0.52–1.15)
Local health service has dedicated tobacco control resources
No	52% (244)	1.0	0.55
Yes	49% (568)	0.91 (0.67–1.25)

* An effective total ban is when smoking is both never allowed and never occurs. † Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. ‡ Wald test for each variable.

3 Aboriginal and Torres Strait Islander employed non-smokers with total indoor smoking bans at work, by sociodemographic factors (n = 417)

Characteristic	% (frequency)*	Odds ratio (95% CI)	P†

Total	93% (387)
Age (years)
18–24	95% (105)	1.0	0.17
25–34	89% (90)	0.47 (0.17–1.26)
35–44	96% (92)	1.31 (0.35–4.92)
45–54	96% (67)	1.28 (0.32–5.07)
≥ 55	89% (33)	0.47 (0.12–1.81)
Sex
Female	95% (204)	1.0	0.10
Male	91% (183)	0.50 (0.22–1.14)
Indigenous status
Aboriginal	94% (349)	1.0	0.43
Torres Strait Islander or both	90% (38)	0.65 (0.23–1.90)
Highest education attained
Less than Year 12	94% (103)	1.0	0.99
Finished Year 12	94% (118)	1.00 (0.32–3.13)
Post-school qualification	93% (165)	0.93 (0.32–2.72)
Treated unfairly because Indigenous in past year
No	95% (193)	1.0	0.35
Yes	92% (188)	0.67 (0.29–1.55)
Smoking status
Ex-smoker	95% (124)	1.0	0.43
Never-smoker	93% (263)	0.71 (0.30–1.67)
Remoteness
Major cities	95% (116)	1.0	0.01
Inner and outer regional	96% (197)	1.13 (0.40–3.18)
Remote and very remote	85% (74)	0.29 (0.11–0.80)
Area-level disadvantage
1st quintile (most disadvantaged)	88% (111)	1.0	0.02
2nd and 3rd quintiles	97% (202)	3.90 (1.50–10.1)
4th and 5th quintiles	93% (74)	1.67 (0.61–4.56)

* Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. † Wald test for each variable.

4 Quitting-related outcomes of Aboriginal and Torres Strait Islander smokers, by home and work smoking bans

	Made quit attempt in past year			Want to quit			Quit attempt of 1 month or longer*
	% (frequency)†	OR (95% CI)	P‡	% (frequency)†	OR (95% CI)	P‡	% (frequency)†	OR (95% CI)	P‡

Home (n)	1594			1540			970
No ban or partial ban	45% (363)	1.0		65% (502)	1.0		45% (201)	1.0
Effective total ban	54% (425)	1.39 (1.10–1.75)	0.006	74% (574)	1.55 (1.22–1.97)	< 0.001	53% (277)	1.38 (1.08–1.77)	0.01
Work (n)	538			515			352
No ban or partial ban	47% (30)	1.0		68% (42)	1.0		51% (19)	1.0
Total ban	52% (246)	1.22 (0.68–2.19)	0.50	76% (344)	1.50 (0.81–2.79)	0.20	59% (186)	1.37 (0.66–2.83)	0.40

OR = odds ratio. * For those with at least one quit attempt in the past 5 years. † Percentages and frequencies exclude refused responses and “don’t know” responses, or when not applicable. ‡ Wald test for each variable.

Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers

Smoking kills one in five Aboriginal and Torres Strait Islander people.1 Encouragingly, there was a steady decrease in the prevalence of daily smoking in the decade to 2012–2013, from 49% to 42% in those aged 15 years or older.2 The 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) found that 62% of smokers had either cut down or attempted to quit smoking in the previous year,3 indicating high levels of motivation to quit.

However, smoking in remote areas has not declined to the same degree as in other areas, and the difference between smoking rates of Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians has not diminished.4 Factors reported to contribute to the high prevalence of smoking among Aboriginal and Torres Strait Islander peoples include ongoing effects of colonisation and dispossession, normalisation of smoking, socioeconomic inequalities and a lack of access to services that support quitting.5–9 Smoking has also been associated with high rates of psychological distress, experiences of racism and binge drinking among Aboriginal and Torres Strait Islander peoples.10,11 Where and how these factors influence the pathway to smoking and quitting has important implications for tobacco control interventions.12

While there has been limited evaluation of strategies to reduce smoking among Aboriginal and Torres Strait Islander peoples, there is some evidence that health professional advice and advertising campaigns increase interest in quitting.13,14 Here, we explore which policies and other factors predict wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers.

Methods

Survey design and participants

The Talking About The Smokes (TATS) project surveyed 1643 current smokers from April 2012 to October 2013 (Wave 1, or baseline). The survey design and participants have been described in detail elsewhere.15,16 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 were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers or recent quitters (ex-smokers who had quit ≤ 12 months before), with equal numbers of men and women and those aged 18–34 and ≥ 35 years. The sample sizes were doubled in four large city sites and 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 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 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.15

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.

Main outcome measure

All smokers were asked “Do you want to quit smoking?” (“yes”, “no” or “don’t know”). This outcome was dichotomised for logistic regression analyses, with “don’t know” responses excluded. Those who reported wanting to quit were also asked how much they want to quit (“a little”, “somewhat” or “a lot”).

Predictors of wanting to quit

Predictors of wanting to quit were explored for key sociodemographic indicators, known predictors of smoking and quitting, and policy exposure variables. These questions, and how they have been grouped for multivariable analyses, are summarised in Appendix 1.

Statistical analyses

All analyses were performed using Stata, version 13.1 (StataCorp). Stata’s 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.17 The relationship between wanting to quit and each predictor variable (Appendix 1) was explored using logistic regression. Variables with two or more categories were then collapsed based on previously established cut-points or those that best fitted the data and context. With the exception of the quitting history subset, which was not included in the multivariable model, variables of importance (with P < 0.15 on adjusted Wald tests) were added hierarchically, commencing with the sociodemographic factors (Box 1). Measures of past quitting activity were not included in the multivariable models because they are indicators of past motivation to quit, which may confound analyses about present intentions. A backwards elimination technique was used to arrive at each model.

Less than 1% of smokers (11/1643) did not respond to the question on wanting to quit and were excluded from all analyses. Of the remainder, data for the 4.8% of smokers (79/1632) who did not know if they wanted to quit were also excluded, leaving 1553 smokers for analysis. While those who declined to respond to questions on predictor variables (≤ 34/1553) were also excluded from relevant analyses, all “don’t know” responses for these variables were combined with other categories as best fitted the data, for a more complete representation of our smoker sample (Appendix 2).

Results

Of the 1553 smokers, 1083 (70%) reported wanting to quit. Of these, 9% (100/1079) wanted to quit “a little”, 31% (330/1079) said “somewhat” and 60% (649/1079) wanted to quit “a lot”.

Many of the 56 predictor variables (Appendix 1) were associated with wanting to quit; those that were not are listed in Appendix 3. Variables that were significant predictors in at least one multivariable model are included in Box 2. Those that only held significant univariate associations are listed in Appendix 4, along with variables for quitting history. Measures of past quitting activity were consistently associated with wanting to quit on univariate analysis, which demonstrates convergent validity.

There were no differences in wanting to quit by age or remoteness (Appendix 3). However, men were less likely than women to want to quit (63% v 76%). While those from areas of greater disadvantage were less likely to want to quit (Box 2), other measures of economic advantage (such as education and employment) did not predict interest in quitting in any of the multivariable models (Appendix 4).

Smokers who said they enjoyed smoking and that smoking is an important part of life were less likely to want to quit (Appendix 4), although only enjoying smoking significantly predicted lack of interest in quitting in the final model (Model 3) (Box 2). Agreement with each of the statements regarding the negative aspects of smoking was associated with increased interest in quitting in unadjusted analyses (Appendix 4). When controlling for other factors (Model 3, Box 2), wanting to quit was higher among those who regretted ever starting to smoke, were very worried about the future effects of smoking on their health, and believed quitting would be beneficial. Believing that not smoking sets a good example to children and perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking also predicted wanting to quit in multivariable modelling, but perceiving disapproval of smoking by mainstream society did not.

More non-daily smokers than daily smokers said they want to quit (78% v 68%). Those assessed as highly nicotine-dependent (based on the Heaviness of Smoking Index) were less likely to want to quit, compared with those who were less dependent (Model 2, Box 2). While a perception that quitting would be very difficult reduced the odds of wanting to quit, even when controlling for relevant attitudes (Model 3, Box 2), reporting strong urges or cravings did not (Appendix 3). Smokers who consumed risky levels of alcohol at least weekly were also less likely to want to quit. On the other hand, smokers who experienced too many worries or went without food or other essentials (because of money spent on cigarettes) were more likely to want to quit, although only having too many worries was predictive in the final model (Box 2).

Very few contextual factors relating to the social environment predicted wanting to quit, and only support from family and friends remained in the final model. Smoke-free environments were also associated with interest in quitting: home (but not workplace) smoking bans predicted wanting to quit when adjusting for sociodemographic factors (Model 2, Box 2), but not when relevant attitudes were considered (Model 3).

All variables relating to exposure to tobacco control policies were positively associated with wanting to quit, except for the presence of dedicated tobacco control staff or resources at the local health service (determined from the project site survey). Only two policy exposure variables appeared to have relationships that were not fully explained (mediated) by relevant attitudes and beliefs: these were having received advice to quit from a health professional in the past year, and having noticed targeted anti-tobacco advertising in the past 6 months.

Discussion

It is encouraging that most Aboriginal and Torres Strait Islander smokers said they want to quit, similar to past studies.6,13,18 We found that a broad range of factors were associated with wanting to quit, including attitudes towards smoking, social normative beliefs, dependence-related measures, other contextual factors and exposure to a range of tobacco control interventions. The diversity of influences highlights the importance of taking a comprehensive approach to tobacco control, through strategies that target the individual, the community and broader aspects of society and the environment.

It is of particular importance that many of the tobacco control strategies assessed were associated with wanting to quit. While it is possible (as with all cross-sectional associations) that wanting to quit led to heightened attention to materials or programs about smoking, these relationships remained significant whether or not other strategies were also noticed. There would seem to be little doubt that the tobacco control strategies assessed were contributing to interest in quitting. In particular, being advised to quit smoking by a health professional and recalling targeted anti-tobacco advertising were predictive of wanting to quit, and these relationships were not contingent on forming relevant attitudes and beliefs. That is, if a health professional says “you should quit smoking”, people become more motivated to do so, even if their beliefs about smoking (eg, whether they will benefit from quitting) remain unchanged. This suggests that these interventions have some direct influence on interest in quitting, whether or not they also influence other beliefs. This motivational effect of brief advice is consistent with past findings,13,19 including in other populations,20 and should affirm the importance of such conversations for health professionals.

While there are mixed findings regarding the effect of media campaigns on quit intentions, there is good evidence that well funded mass media campaigns promote quitting.21 Our results suggest that targeted messages have added potency for Aboriginal and Torres Strait Islander peoples, beyond that of mainstream mass media messages, which are thought to be equally effective for Indigenous peoples as for the general population.14 The added potency of targeted and local advertising may be due to greater cultural relevance,14,22,23 or because of community involvement and leadership in its development. For example, ACCHSs often use targeted advertising and information that may incorporate Aboriginal and Torres Strait Islander cultural beliefs, holistic wellbeing, family messages, storytelling, role modelling and community elders.24 In general, targeted messages are indicated where beliefs and sources of motivation differ from those in the general population.25 Elsewhere in this supplement, we report that beliefs about harm to others appear particularly motivating,26 and that smokers who recalled more targeted or local targeted advertising were more likely to hold these beliefs.27

Our results emphasise previous findings regarding the power of others to motivate quitting.7,19,26,28,29 Similar findings have been reported for other indigenous populations.30–32 In this regard, it is relevant that having more friends and family members who smoke did not reduce interest in quitting in our sample, consistent with previous findings.13 That said, social networks may be more important in making and sustaining quit attempts, as reported elsewhere.33,34

Our finding that fewer men wanted to quit is cause for concern, particularly when interpreted alongside findings elsewhere in this supplement that fewer men are making quit attempts.35 Sex was not found to predict wanting to quit in a similar but smaller study conducted in regional New South Wales.13 Further, national surveys have not shown large differences between the sexes in the decline of smoking uptake or the rise of successful quitting among Aboriginal and Torres Strait Islander peoples.36 International literature shows the relationship between sex and quitting is complex and appears to differ according to age, social standing and other factors such as differential use of stop-smoking medications,37,38 which we have not explored here.

In contrast to the general population, where younger, economically advantaged smokers report greater interest in quitting,39,40 wanting to quit was not predicted by age, remoteness, education or employment in our results, despite evidence of smaller reductions in smoking among those in remote areas and older age groups.2 This suggests differences in smoking prevalence may be due to the challenges of quitting successfully for these smokers, not lack of motivation.

Similarly, past research shows that smokers who experience mental ill health are no less interested in quitting, consistent with our findings for smokers who reported having too many worries or feeling depressed.41–43 However, these people are less likely to succeed, particularly if they are economically disadvantaged.41–43 The solution for these smokers extends beyond building motivation to quit. In other settings of disadvantage, a combination of short-term strategies, which deal with immediate challenges to quitting, and longer-term policy interventions, which tackle factors that cause disadvantage and marginalisation, is recommended.44 These recommendations are consistent with taking a comprehensive approach to tobacco control.

Strengths and limitations

The TATS project sample was broadly representative of the Aboriginal and Torres Strait Islander population, albeit with some inconsistent sociodemographic differences when compared with the 2008 NATSISS sample. It is possible that a bias towards those who were more connected to the local health service boosted levels of exposure to policies or programs such as brief intervention or use of local educational materials, which may have inflated our estimates of these exposures. However, comparisons between the TATS project and the 2008 NATSISS show that similar proportions of smokers had seen a health professional in the previous year and had attempted to quit in the previous year,15 which reassures us that there was not strong systematic bias caused by recruitment by health service staff.

While interviewer-assisted surveys could lead to a social desirability bias towards wanting to quit, evidence from elsewhere suggests that respondents are equally or less likely to say they want to quit in interviewer-assisted telephone surveys compared with postal or online surveys.45,46 Social desirability biases can also be culturally moderated, which we sought to overcome by engaging local interviewers to reduce the social distance between the interviewer and participant.47 Given there was no evidence of any strong or systematic bias, we believe it appropriate to compare our estimates and cross-sectional associations with other surveys and to generalise our findings to the national Aboriginal and Torres Strait Islander population.15

While we excluded 4.8% of smokers who did not know if they want to quit (to better predict wanting to quit, as a dichotomous outcome), the demographic characteristics of these smokers were similar to those who were included in our analyses.

Using a hierarchical approach for the multivariable analysis allowed us to determine the degree to which policy exposures could be accounted for by relevant attitudes and beliefs (ie, those that precede wanting to quit). The hierarchical model unmasks policy exposure variables that have influenced wanting to quit by strengthening relevant attitudes and beliefs on the pathway to quitting. It is likely that we have not measured all attitudes and beliefs that are influenced by the tobacco control interventions assessed, which may explain why some interventions remained in the final model (ie, appearing to exert a direct effect on wanting to quit). However, although not exhaustive, the variables included in the multivariable modelling have been shown in other articles in this supplement to be relevant and important, and have also been shown to be relevant to a diverse range of societies and tobacco control environments.47 Further, the strong relationships between wanting to quit and past quitting activity mirror findings from other populations, which demonstrate that repeated (and failed) attempts to quit are common among those who are most interested in quitting.48,49 This validates the question “Do you want to quit?” as an indicator of interest in quitting among Aboriginal and Torres Strait Islander peoples.

It is important to remember that some of the predictors of wanting to quit are likely to be caused by wanting to quit. Further, at least for the general population, determinants of success once a quit attempt is initiated are quite different to those for wanting and attempting to quit.48,50,51 Some of the variables that were unrelated to interest in quitting among Aboriginal and Torres Strait Islander smokers are likely to predict quit success. Longitudinal research is needed to assess how factors associated with wanting to quit influence the pathway to making and sustaining quit attempts.

With these considerations in mind, it is clear that most Aboriginal and Torres Strait Islander smokers want to quit. The broad range of factors associated with wanting to quit highlight the importance of taking a comprehensive approach to tobacco control. While it is likely that a continuation of the strategies already in use will enable high levels of motivation to be maintained, the next challenge will be to translate this into more successful quitting.

1 Hierarchical model for multivariable analysis

2 Hierarchical model of associations with wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*

	Smokers	Univariate† (n = 1553)		Model 1‡ (n = 1454)		Model 2§ (n = 1416)		Model 3¶ (n = 1503)
	% (frequency)	Odds ratio (95% CI)	P**	AOR (95% CI)	P**	AOR (95% CI)	P**	AOR (95% CI)	P**

Do you want to quit? — Yes	70% (1083)			—	—	—	—	—	—
Sociodemographic factors
Male	63% (476)	0.55 (0.40–0.76)	< 0.001	0.65 (0.47–0.90)	0.01	0.68 (0.49–0.94)	0.02	0.59 (0.42–0.83)	0.002
Area-level disadvantage††	68% (849)	0.59 (0.42–0.84)	0.004	0.53 (0.37–0.76)	0.001	0.56 (0.38–0.82)	0.003	0.61 (0.41–0.90)	0.01
Policy exposure variables
Advised to quit by health professional‡‡	78% (675)	2.50 (1.91–3.26)	< 0.001	2.07 (1.56–2.74)	< 0.001	1.71 (1.24–2.35)	0.001	1.42 (1.04–1.94)	0.03
How often warning labels noticed§§
Never	45% (71)	1.0	< 0.001	1.0	< 0.001	1.0	< 0.001	dropped	—
Sometimes or don’t know	58% (204)	1.65 (1.03–2.63)		1.50 (0.97–2.32)		1.34 (0.84–2.14)
Often	78% (755)	4.31 (2.64–7.04)		3.02 (1.93–4.73)		2.58 (1.59–4.20)
How often news stories noticed¶¶
Never	59% (271)	1.0	< 0.001	1.0	0.03	1.0	0.04	dropped	—
Sometimes or don’t know	71% (512)	1.73 (1.33–2.26)		1.30 (0.99–1.71)		1.33 (1.00–1.78)
Often	81% (297)	3.03 (2.03–4.53)		1.75 (1.15–2.68)		1.73 (1.12–2.68)
How often advertising or information noticed¶¶
Never	48% (112)	1.0	< 0.001	dropped	—	dropped	—	dropped	—
Sometimes or don’t know	68% (403)	2.26 (1.60–3.19)
Often	79% (548)	4.09 (2.67–6.27)
Noticed targeted advertising¶¶	80% (592)	2.57 (2.03–3.27)	< 0.001	1.75 (1.36–2.25)	< 0.001	1.79 (1.38–2.32)	< 0.001	1.74 (1.32–2.31)	< 0.001
Noticed local advertising¶¶	84% (203)	2.58 (1.77–3.74)	< 0.001	dropped	—	dropped		dropped
Contextual factors (other moderators)
High nicotine dependence***	62% (190)	0.65 (0.49–0.86)	0.003	—	—	0.63 (0.48–0.83)	< 0.001	dropped
High perceived difficulty of quitting	66% (360)	0.77 (0.58–1.02)	0.07	—	—	0.59 (0.44–0.80)	0.001	0.54 (0.39–0.74)	< 0.001
Smoking-induced deprivation¶¶	76% (265)	1.49 (1.08–2.05)	0.02	—	—	1.51 (1.04–2.20)	0.03	dropped
Satisfied with life	67% (879)	0.42 (0.28–0.64)	< 0.001	—	—	0.55 (0.37–0.83)	0.005	dropped
Risky alcohol intake (binge drinking) weekly‡‡	63% (349)	0.63 (0.49–0.80)	< 0.001	—	—	0.62 (0.47–0.82)	0.001	0.66 (0.49–0.88)	0.005
How often too many worries to deal with¶¶
Never	60% (219)	1.0	< 0.001	—	—	1.0	0.002
Sometimes or don’t know	71% (644)	1.64 (1.21–2.22)		—	—	1.76 (1.24–2.51)		1.60 (1.10–2.32)	0.01
Often	79% (214)	2.52 (1.74–3.65)		—	—	2.27 (1.41–3.66)		2.15 (1.29–3.58)
Support to quit from family and friends	78% (729)	2.54 (1.90–3.40)	< 0.001	—	—	2.03 (1.48–2.79)	< 0.001	1.51 (1.10–2.07)	0.01
Smoke-free home (effective indoor ban)	74% (574)	1.55 (1.22–1.97)	< 0.001	—	—	1.41 (1.08–1.84)	0.01	dropped
Policy-relevant attitudes and beliefs (mediators)
You enjoy smoking†††	61% (594)	0.28 (0.20–0.41)	< 0.001	—	—	—	—	0.32 (0.23–0.44)	< 0.001
If you had to do it over again, you would not have started smoking†††	75% (907)	2.79 (1.96–3.97)	< 0.001	—	—	—	—	1.55 (1.06–2.27)	0.02
Community leaders where you live disapprove of smoking†††	77% (504)	1.89 (1.47–2.43)	< 0.001	—	—	—	—	1.61 (1.19–2.19)	0.002
Being a non-smoker sets a good example to children†††	73% (1029)	4.64 (2.91–7.38)	< 0.001	—	—	—	—	2.31 (1.38–3.86)	0.002
Very worried about future health effects	90% (500)	6.20 (4.44–8.65)	< 0.001	—	—	—	—	3.43 (2.35–5.00)	< 0.001
High perceived benefit from quitting	82% (780)	4.42 (3.25–6.00)	< 0.001	—	—	—	—	2.21 (1.59–3.07)	< 0.001

AOR = adjusted odds ratio. * Current smokers in the baseline survey of the Talking About The Smokes project, excluding those who did not know if they want to quit smoking and others for whom questions were declined or not applicable. † Variables with significant univariate but not multivariable associations are in Appendix 4. ‡ Policy exposure variables plus sociodemographic factors. § Model 1 plus contextual factors. ¶ Model 2 plus policy-relevant attitudes and beliefs. P values for overall variable significance, using adjusted Wald tests. †† Socio-Economic Indexes for Areas quintiles 1–3. ‡‡ In the past year. §§ In the past month. ¶¶ In the past 6 months. * Heaviness of Smoking Index score, 4–6. ††† “Agree” or “strongly agree” responses.

Talking About The Smokes: a large-scale, community-based participatory research project

Community-based “participatory research” (PR) is desirable because it fosters partnerships between a community and research agencies, enabling inclusivity, interdependence and democratic knowledge production to reduce health inequalities.1–4 Support for PR is particularly strong when research involves indigenous peoples5,6 as it promotes self-determination, creating more transparent and equitable conditions for knowledge creation and benefit sharing.3,7 PR as a methodology may range from being consultative5 through community-directed8 to community-controlled, where community groups exercise the highest expression of autonomy over research, assisted by research institutions.9

In Australia, one Aboriginal human research ethics committee (HREC) will only approve a research project when “there is Aboriginal community control over all aspects of the proposed research”, including design, data ownership, interpretation and publication.10 Other approval criteria include the betterment of Aboriginal peoples’ health, cultural sensitivity and a capacity to benefit. These are hallmarks of PR, and there are now World Health Organization guiding principles specific to indigenous peoples,7 along with guidelines,11,12 joint statements,13–15 and a systematic review,1 to influence PR design and complement guidelines for ethical research involving Indigenous Australians.16 The WHO principles for PR reflect experience in various countries and provide guidance on the joint management of research by research institutions and indigenous peoples. These principles are described as being “applicable everywhere and to all fields of research involving Indigenous Peoples”.7

In this supplement, we report on the Talking About The Smokes (TATS) project, a large-scale PR collaboration between Aboriginal and Torres Strait Islander peoples, their representative bodies, and researchers. This national research project was initiated in 2010 to examine pathways to quitting smoking and the impact of tobacco control policies in the Aboriginal and Torres Strait Islander population. The TATS project is one of many studies within the International Tobacco Control Policy Evaluation Project (ITC Project) to follow nationally representative cohorts of smokers, to measure psychosocial and behavioural impacts of tobacco control policies.17 However, it is the first to sample only a high-prevalence subpopulation within a country.18

In this article, we describe the TATS project PR methodology according to the WHO guiding principles, to assist others planning large-scale PR projects.

Background

In 2012–2013, 42% of the Aboriginal and Torres Strait Islander population aged 15 years or older were daily smokers — 2.6 times the age-standardised prevalence among other Australians.19 Australian governments aimed to halve the Indigenous Australian smoking rate by 2018 (from the 2009 baseline) through a range of Indigenous tobacco control initiatives.20 Funded by the Australian Government in support of these national initiatives, the TATS project was conducted mainly through Aboriginal community-controlled health services (ACCHSs).

ACCHSs provide comprehensive primary health care services to more than 310 000 people (2010–11), with nearly 80% identifying as Aboriginal and/or Torres Strait Islander. The 150 ACCHSs located across Australia are almost entirely Aboriginal-controlled, with a governance structure comprising elected members of the Aboriginal community.21 Although funded largely by the Australian Government,21 they are independent not-for-profit agencies, established by Aboriginal leaders from 1971 in response to significant unmet health needs.22 ACCHSs were involved in the TATS project partly because those most affected by the research outcomes were likely to be patients and staff of these services, but also because of the representativeness of ACCHSs at the local community level, which enabled community control over the research process at each site.

The TATS project was led by the Menzies School of Health Research (Menzies) in a formal partnership with the National Aboriginal Community Controlled Health Organisation (NACCHO). The research team included researchers from Menzies, the Centre for Excellence in Indigenous Tobacco Control, Cancer Council Victoria, two state affiliate organisations of NACCHO (Affiliates) — the Queensland Aboriginal and Islander Health Council (QAIHC) and the Aboriginal Health and Medical Research Council of New South Wales (AH&MRC) — and researchers representing NACCHO. The researcher from Cancer Council Victoria is an investigator on other ITC Project surveys. Project support staff were employed at Menzies and NACCHO, and at 34 local ACCHSs as research assistants (Box 1).

The project used two waves of survey data in 35 locations (the 34 ACCHSs and a community in the Torres Strait). In the first of these waves, 2522 community members and 645 ACCHS staff were surveyed from April 2012 to October 2013. The research methods and baseline sample are described elsewhere.18

Methods

The WHO guiding principles were adapted from their narrative form into a reporting framework in which the text (verbatim) was rearranged into seven themes with numbered subsections (Appendix 1). A condensed version of the framework is shown in Box 2. This framework was used to assess the PR process in the TATS project. Anticipated and unanticipated benefits of the project were sourced from the research protocol, ethics submissions and anecdotal reports from ACCHSs.

Throughout this report, links to the numbered subsections of the framework are shown in parentheses. The framework and the WHO principles refer to indigenous peoples as those “with clearly identifiable community and leadership structures … and a significant political voice”.7 Our references to Indigenous peoples include Aboriginal peoples and Torres Strait Islanders and their representative bodies, such as NACCHO, ACCHSs and Affiliates — all independent but related entities.

Permission to use the framework was provided by the lead author of the WHO principles (Harriet Kuhnlein, Founding Director, Centre for Indigenous Peoples’ Nutrition and Environment, Quebec, Canada, personal communication, February 2014).

Results

The PR approach adopted by the TATS project is described using the seven themes from the adapted framework (Box 2).

1. Consultation and approval

The TATS project was initiated as a result of conversations between three researchers (from Menzies, Cancer Council Victoria and the Centre for Excellence in Indigenous Tobacco Control), one of whom is Aboriginal, and was influenced by the usefulness of ITC Project surveys in other settings. A decision was made to invite Aboriginal organisations as partners. Initial contact with these organisations was made at a meeting of all Affiliates, after which two researchers (from QAIHC and AH&MRC) agreed to participate. In view of the national significance of the proposed research and synergies with national tobacco control policy and community priorities, NACCHO proposed a partnership with Menzies, which was accepted, and NACCHO representatives joined the research team (1.1–1.5).

2. Partnerships and research agreements

Several types of research agreements, some legally binding, were made between the partners (Box 3). The earliest agreement comprised a memorandum of understanding (MOU) initiated by NACCHO to guide the shared development of the research protocol and funding proposal with Menzies, and to ensure consistency with the research and policy priorities of both institutions (2.1). Other agreements comprised two funding contracts between Menzies and the Australian Government and a subcontract with NACCHO, the research protocol, site agreements and consent forms.

Other research team members chose not to make legal agreements between their employers and Menzies; their involvement was sustained by common interests and a history of existing relationships between individuals. Researchers from QAIHC and AH&MRC received endorsement from the Aboriginal leadership of these bodies to participate as individuals in the project.

The research team collaboratively developed the research protocol, with review by the Project Reference Group (PRG), and this was endorsed by the NACCHO Board 18 months after the MOU was signed. The protocol articulated the roles and responsibilities of all partners, the agreed conditions and all steps of the research process (2.2–2.6). Menzies was the administering agency and project manager, and NACCHO acted as advisor for responsible research conduct, communication and coordination involving ACCHSs, in collaboration with other research team members.

Local ACCHSs were informed about the TATS project and the NACCHO–Menzies research partnership and invited to express an interest in participation, pending funding. Although ACCHSs had minimal involvement in the development of the research protocol, it formed the basis of the individually negotiated site consent forms and site agreements (Box 3). All parties to these agreements committed to the successful completion of the research, but could withdraw at any time with notice (2.7–2.8).

3. Communication

Lines of authority within participating Aboriginal organisations were respected; the project staff communicated with managers, chief executive officers and boards where appropriate (Box 1). The key to coordination was the employment of project staff to facilitate engagement between the research team and sites using existing ACCHS sector networks, communication between Menzies and NACCHO, and reporting to the NACCHO Board (3.1).

The NACCHO Board approved the structure, role and membership of the research team and the PRG. Appointments to the PRG were facilitated by NACCHO and comprised Aboriginal peoples and Torres Strait Islanders from all Affiliates and a member of the NACCHO Board as Chair. This ensured the PRG could represent ACCHSs from all jurisdictions. The PRG provided advice, monitored the ethical conduct of research, and assisted in prioritising data analysis (3.2). Members of the PRG were also involved in the interpretation of results, increasing the involvement of Indigenous peoples in this part of the research process.

Communication responsibilities were articulated in the research protocol, funding agreements and site agreements, and included the release of progress reports and a national knowledge exchange forum involving all sites (3.3–3.4).

4. Funding

The initiating three researchers procured establishment funding to negotiate and make agreements with key stakeholders and develop the research protocol and instruments. Thereafter, all research team members had oversight of project fund seeking, as the establishment of partnerships preceded the acquisition of these funds (4.1).

To assure mutual interests, primary contract negotiations involving Menzies and the funder were synchronously aligned with the development of the subcontract with NACCHO. All site agreements were also contracted with Menzies, which funded ACCHSs to undertake local surveys by employing research assistants (4.2) (Box 3).

5. Ethics and consent

Approval from three Aboriginal HRECs and two other HRECs with Aboriginal subcommittees was secured across four jurisdictions before finalisation of the research protocol and signing of the funding contract with NACCHO (5.2–5.3). The MOU, ethics applications and research protocol committed the parties to adhere to ethics guidelines16 and conform to NACCHO data protocols.23 These protocols were developed and endorsed by the ACCHS sector to affirm the importance of Aboriginal peoples and their representative bodies acting as owners and custodians of their own data (5.1, 5.4, 5.7).

Three levels of consent were sought and obtained: Aboriginal collective consent at the national level through NACCHO;24 local community collective consent from each individual ACCHS and the Torres Shire Council (representing the Torres Strait community, as there is not a local ACCHS); and informed consent procured from individual survey participants by research assistants (5.5) (Box 2).

Research assistants had some control over how data would be collected in their community, thereby accommodating cultural and geographic diversity across sites. The consent of study participants was obtained in writing using consent forms approved by the research team as per ethics guidelines (5.6).16

6. Data

Primary contract negotiations stated that intellectual property rights to products arising from the project were vested in Menzies. Through subcontracting, NACCHO and individual ACCHSs were granted a perpetual licence to use, adapt and publish project outputs in accordance with the research protocol and, therefore, the NACCHO data protocols (6.1). The primary funding contract, NACCHO subcontract and research protocol stipulated that raw (unanalysed) data collected from ACCHSs remained the property of the specific ACCHSs “when considered both in isolation and at a national level”. Site agreements clarified that: the collected data were to be used by the research team only as outlined in the research protocol; release of information identifying ACCHSs required their review; and publication of aggregated national results required review by NACCHO (or Affiliates where jurisdictions were identified) (6.2).

Confidential information was protected using a password-protected database, with separate storage of a unique identifying code available only to approved staff and research team members (6.3). This code was necessary for the re-identification of participants in the follow-up survey a year after the baseline survey.

Research agreements ensured that data analyses and interpretations in publications and conference presentations were agreed on by the research team or through joint meetings with the PRG, and then reviewed by NACCHO before submission for publication (6.4). Authorship of manuscripts was negotiated based on international criteria,25 with capacity for Indigenous members of the research team, PRG or project staff, or Indigenous research assistants, to be authors (6.5). ACCHSs were also provided with summaries of their local data in clear language and in formats enabling their independent use (6.6).

ACCHSs’ ownership of their unanalysed data meant that new research requests unrelated to the original agreement would require endorsement from the relevant ACCHS or, on national matters, the NACCHO Board and the PRG (6.7).

7. Benefits of the research

Anticipated research benefits were identified in all research agreements and other information provided to ACCHSs and participants (7.1) (Box 4). No commercial benefits were considered likely (7.2). The recruitment of Aboriginal and Torres Strait Islander peoples to the PRG and the employment of three project staff at NACCHO and 101 local research assistants in ACCHSs helped build individual Indigenous and organisational capacity (7.3) (Box 4). All except seven of the research assistants were local Indigenous people. Funding was provided to ACCHSs for these appointments and to compensate survey participants (in the form of vouchers). Anecdotal benefits to survey participants and services were freely communicated (Box 5).

Discussion

The TATS project exemplifies community-directed research,8 where participation between partners is democratised. While the design of the TATS project was shaped by the institutional, policy and research experience of Aboriginal organisations, research agencies and individual researchers, it closely mirrored the WHO’s PR principles. The TATS project involved 34 ACCHSs conducting baseline and follow-up surveys, making it one of the largest PR projects in Australia. We can affirm that large-scale PR involving vulnerable populations is achievable.

When communities and researchers seek solutions to the same health problems, negotiating this interdependence into a research partnership can help community researchers feel like they are “doing meaningful public health work, not just conducting research”.26 Ultimately, PR relies on forming the right partnerships.27 The relational ethics of the TATS project were negotiated through pre-existing trust between individuals from partner organisations and the individual relationships that developed during the project. They were also negotiated formally through research agreements that embedded community “ways of knowing” and Indigenous ownership over products such as research data.5 This meant that ACCHSs retained autonomy over their collected local information, including into the future — an outcome normally considered challenging.6 Establishing partnerships can take months, particularly where legal agreements are negotiated. Securing an establishment grant for TATS project preparatory work, as well as being transparent about funding uncertainty and research time frames, allowed time for partnerships to develop.

Through NACCHO, the project received the approval and involvement of the Aboriginal health leadership of the ACCHS sector nationwide. Research assistants recruited by ACCHSs from the local population enhanced trust and increased participant recruitment, as did the provision of financial compensation. These strategies are known to increase research response rates in minority populations.26,28,29 Aboriginal peoples and Torres Strait Islanders were employed and involved in all aspects of the project, from conception and design to analysis and dissemination. While the WHO principles promote active Indigenous involvement, including self-determination over the degree of research involvement, advice on building Indigenous capacity through Indigenous employment and career development is more explicit in other guidelines.13,1 5

We did not attempt to quantify congruence of our project with PR principles,1,8 but the framework we adapted served to structure and focus our reporting “beyond the rhetoric”,5 illustrating applied PR principles in large-scale community-based research. Investment in a research process that is participatory, in both “methodology and method”, is rewarding and sometimes more important than the outcome.30 Participation can empower communities and is recognised as an outcome in itself.31 Community participation in research delivers social and cultural validity when inquiries are aligned with the needs and priorities of those being researched, and better external validity of findings for generalisability.3 Achieving this through PR may be more costly in the short term but in the long term builds health equity32 and facilitates translation of research into policy.3

PR is common but there is no single PR strategy, as self-determined community priorities are unique.4 Sharing our strategies may encourage others to adopt similar research models involving indigenous peoples for equitable knowledge creation, and to build stronger future partnerships.

1 Governance structure of the Talking About The Smokes project

NACCHO = National Aboriginal Community Controlled Health Organisation. ACCHS = Aboriginal community-controlled health service. CEO = chief executive officer. ITC Project = International Tobacco Control Policy Evaluation Project.

2 Condensed framework: guiding principles for participatory health research involving research institutions, Indigenous peoples and their representative bodies*

Theme

Subsection

The guiding principles refer to:

1. Consultation and approval

1.1–1.3

Initiation of research and making contact

1.4–1.5

Approval for the research to proceed

2. Partnerships and research agreements

2.1–2.4

Equality of research relationships, joint preparation of a research agreement and research proposal

2.5–2.6

Development of agreed research processes

2.7–2.8

Joint obligations towards the research

3. Communication

3.1

Clarification of, and respect for, the lines of authority of the partners

3.2

Committee selection by Indigenous peoples (for communication, facilitation and promotion); the committee should represent all relevant community-controlled organisations

3.3–3.4

Maintenance of communication, including progress reports, results and implications of the research

4. Funding

4.1–4.2

A joint commitment to fund seeking, and agreement of sources in advance

4.3

Research institutions’ obligation to ensure Indigenous peoples are involved where resources or capacity are lacking

5. Ethics and consent

5.1–5.2

Respect for ethical guidelines, approval from human research ethics committees and Indigenous-controlled ethics committees

5.3

Research commencing only after ethics approval is received and signed agreements are finalised

5.4

Research conforming to additional protocols of the Indigenous peoples involved

5.5

Consent for research at various levels: individual (study participants), representatives of Indigenous peoples, and the umbrella Indigenous organisation

5.6

A jointly agreed consent-seeking process

5.7

Umbrella Indigenous organisation demonstrating the collective consent of Indigenous peoples

6. Data

6.1–6.2

Intellectual property rights, benefit sharing and boundaries pertaining to information use

6.3

Confidentiality and limiting access to research data

6.4

Joint review and interpretation of data before publication

6.5

Authorship or acknowledgement of participants in joint research

6.6

Formatting data and reports for independent use by Indigenous peoples

6.7

Indigenous ownership of data and authorisation for further use

7. Benefits of the research

7.1

Obligation for research to provide short-term and long-term benefits for Indigenous peoples, including provision of health care where lacking

7.2

Disclosure of potential economic benefits of the research

7.3

Research benefits including training, employment, general capacity building and improved health status or services (or prospects for such improvement)

* Adapted from the World Health Organization, 2003.7 See Appendix 1 for the full framework.

3 Types of research agreements used in the Talking About The Smokes (TATS) project

Research agreement

Function

Signatories

Memorandum of understanding

Commit parties to developing a research partnership

Menzies, NACCHO

Funding contracts

Fund both the establishment phase and the full TATS project

Menzies, Australian Government Department of Health and Ageing

Subcontract

Fund NACCHO project staff to deliver TATS services

Menzies, NACCHO

Research protocol

Document the agreed research processes (goals, planning, design, methods, consent, data collection, analysis, interpretation, dissemination and reporting)

Research team members (and endorsed by NACCHO Board)

Site agreements

Articulate the terms of engagement including roles and responsibilities, and provide funding for employment of research assistants and purchase of consumables

Menzies, ACCHSs

Site consent forms

Document collective consent of the community served by the ACCHS

Menzies, ACCHSs

Survey consent forms

Document individual consent

Survey participants, research assistants

Menzies = Menzies School of Health Research. NACCHO = National Aboriginal Community Controlled Health Organisation. ACCHS = Aboriginal community-controlled health service.

4 Benefits of the Talking About The Smokes project

Benefits

Explanation

To study participants

Those identified as having an interest in quitting smoking were referred to health personnel in ACCHSs for quit support
Financial compensation for time spent doing surveys

To health services

Provision of local information about smoking and tobacco control encouraged ACCHSs to develop:
- more effective local quit initiatives (eg, quit smoking programs were newly established in some ACCHSs; health promotion activities were improved)
- workplace smoking policies
Funds were provided for the employment of local staff on the project

Towards employment

Employment of local Indigenous and non-Indigenous Australians:
- 101 research assistants across 35 sites, with all but seven being Aboriginal or Torres Strait Islander; three NACCHO staff (one of whom was Aboriginal); two Menzies staff (one of whom was Torres Strait Islander)
Some research assistants were offered ongoing employment in ACCHSs

Enhancing research capacity

Onsite training of research assistants by regional coordinators, which was also sometimes attended by other ACCHS staff
ACCHSs’ ownership of their survey data, enabling further analyses at each service’s discretion

Towards partnerships

Collaborative relationships between partners in the research sector, the Aboriginal community and communities in the Torres Strait

Towards Indigenous participation

Involvement of Indigenous peoples in all aspects of the project

Towards improved knowledge exchange

Results from the project will inform improved tobacco control activities and policies to reduce the harm caused by smoking
This knowledge exchange will be enhanced by the involvement of the potential users of this research, especially ACCHSs, throughout the project

ACCHS = Aboriginal community-controlled health service. NACCHO = National Aboriginal Community Controlled Health Organisation.

5 Quote from a project site illustrating the benefits of the Talking About The Smokes project

“In our 2 years doing the Talking About The Smokes project, [our] Aboriginal Corporation has been able to engage with over 125 community members (smokers!!), allow a staff member to get paid, and allow a staff member to be in a leadership role in the community. These results from the 2 years will now feed into the Tobacco Action Group that is newly formed for [our] region. We supported World No Tobacco Day last year, with over 60 community members attending, and hope for a repeat this year.”

Matt Burke, OAM, Chief Executive Officer, Mungabareena Aboriginal Corporation, Wodonga, Victoria, March 2014 (with permission).

Talking About The Smokes: summary and key findings

Transforming the evidence to guide Aboriginal and Torres Strait Islander tobacco control

The baseline cross-sectional results from the Talking About The Smokes project outlined in this supplement (and summarised in the Box) provide the most detailed national evidence yet to guide practice and policy to reduce the harm caused by tobacco smoking among Aboriginal and Torres Strait Islander peoples. The national prevalence of daily smoking in the Aboriginal and Torres Strait Islander population is falling, but at 42% is still 2.6 times that of other Australians.1 Research evidence to guide Aboriginal and Torres Strait Islander tobacco control has been constrained by the uncertainties of generalising from small local research projects or from the large body of research in other populations. There have been competing hypotheses about whether Aboriginal and Torres Strait Islander smoking and quitting behaviour is similar to or different from other populations. These new results suggest many similarities with other populations.

We found the proportion of Aboriginal and Torres Strait Islander daily smokers who want to quit, have made a quit attempt in the past year, live in smoke-free homes and work in smoke-free workplaces is similar to that of the general population. Similar proportions also demonstrate knowledge of the most harmful health effects of smoking and hold negative personal attitudes towards smoking.

But there are also differences. Fewer Aboriginal and Torres Strait Islander daily smokers than other Australians have ever made a quit attempt or sustained a quit attempt for at least a month, and a lower proportion agree that social norms disapprove of smoking. Even though similar proportions agree that nicotine replacement therapy and stop-smoking medicines help smokers to quit, fewer have used these. In contrast, a higher proportion recalled being advised to quit by a health professional in the past year.

There are also differences in smoking and quitting behaviour and beliefs within the Aboriginal and Torres Strait Islander population, although the socioeconomic gradients were not consistent. For example, more employed people than those who were not employed wanted to quit, had ever tried to quit, had sustained a quit attempt for at least a month, knew about the harms of smoking, had a smoke-free home, had been advised to quit and had used nicotine replacement therapy or stop-smoking medicines. But there were no differences by employment status in quit attempts in the past year, recall of exposure to health information or in many of the attitudes towards smoking.

Using this new information, health staff working directly with Aboriginal and Torres Strait Islander smokers can be encouraged to do more, knowing that most of the smokers they see will want to quit, already know that smoking and passive smoking are harmful, and are likely to live in a smoke-free home and have a history of recent quit attempts. They can be confident that their messages will be understood and welcomed, then focus on the more difficult task of helping people to successfully sustain their quit attempts.

Those working in clinics can build on their existing good work in ensuring that most Aboriginal and Torres Strait Islander smokers regularly receive brief advice about smoking cessation. They can encourage more smokers to use evidence-based measures to prevent relapse during their next quit attempt, such as stop-smoking medicines, the telephone Quitline, and quit-smoking courses, clinics and groups.

Those working in health promotion will need to continue to reinforce and enhance social norms about being smoke-free, to encourage quit attempts and to support smokers trying to sustain quit attempts. There is a need for continued mainstream and national social marketing campaigns, especially those that build on the particular salience of Aboriginal and Torres Strait Islander smokers’ concerns about the harmful effects of their smoking on others. Local and Aboriginal and Torres Strait Islander campaigns also appear to be useful.

There are also messages for public health professionals, policymakers, funders and managers. They can justify investing health resources in tobacco control, not only because smoking causes 20% of Aboriginal and Torres Strait Islander deaths,2 but also because improvement is clearly possible. Our findings support maintaining an ongoing commitment to a comprehensive approach to Aboriginal and Torres Strait Islander tobacco control, rather than relying excessively on any single strategy or element. Those working directly with Aboriginal and Torres Strait Islander smokers should be made aware of this new evidence and aided in reorienting their practice to accommodate it. One of the specific challenges will be how to efficiently fund targeted social marketing activity, without wasting social marketing resources through too much fragmentation.3

Most recent national policy attention has concentrated on the large increase in dedicated funding initiated by the previous federal government through the Tackling Indigenous Smoking program, followed by the announced cuts to this funding and the review of the program in 2014. The information in this supplement is useful to guide the evolution of the program, but also reminds us that this is only part of the story. Aboriginal and Torres Strait Islander smoking is also being tackled through mainstream tobacco control activities (advertising campaigns, pack warnings and plain packaging, and smoke-free regulation) and activities already incorporated into routine health care (brief advice and individual cessation support).

This is only the beginning of the evidence that will emerge from the Talking About The Smokes project. It was designed primarily as a cohort study, and analyses of the prospective longitudinal data of the 849 recontacted smokers and ex-smokers will enable more definitive causal interpretations. The involvement of Aboriginal and Torres Strait Islander people and the Aboriginal community-controlled health service sector in all aspects of this project will facilitate the translation of the results into improved practices and policies that will reduce the harm caused by smoking in Aboriginal and Torres Strait Islander communities.

Key findings from the baseline survey of the Talking About The Smokes project

We interviewed a nationally representative sample of 2522 Aboriginal and Torres Strait Islander people from 35 locations across Australia, including 1643 smokers (1392 daily smokers), 78 ex-smokers who had quit ≤ 12 months before, 233 ex-smokers who had quit > 12 months before, and 568 never-smokers.

Quitting (doi: 10.5694/mja15.00202, 10.5694/mja15.00199, 10.5694/mja15.00105)

70% of smokers want to quit
69% of daily smokers had ever made a quit attempt
48% of daily smokers had made a quit attempt in the past year
47% of daily smokers who had made a quit attempt in the past 5 years had sustained an attempt for at least 1 month
70% of daily smokers who had made a quit attempt in the past 5 years had strong cravings during their most recent quit attempt, and 72% found it hard to be around smokers

Second–hand smoke (doi: 10.5694/mja14.00876, 10.5694/mja15.00200)

53% of daily smokers reported that smoking was never allowed anywhere inside their home
88% of employed daily smokers reported that smoking was not allowed in any indoor area at their workplace
77% of daily smokers agreed that smoking should be banned everywhere (both indoors and outdoors) at Aboriginal community-controlled health services, 93% agreed it should be banned indoors at other Aboriginal organisations, and 51% agreed it should be banned at outdoor festivals and sporting events

Knowledge of the health effects of smoking and second–hand smoke (doi: 10.5694/mja14.00877)

Most daily smokers reported knowing that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%)
Most daily smokers reported knowing that second-hand smoke is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%)

Personal attitudes towards smoking (doi: 10.5694/mja14.01535)

78% of daily smokers agreed that if they had to do it over again, they would not have started smoking
81% of daily smokers agreed that they spend too much money on cigarettes
32% of daily smokers agreed that smoking is an important part of their life

Social norms about smoking (doi: 10.5694/mja14.01534)

62% of daily smokers agreed that mainstream society disapproves of smoking, and 40% agreed that their local community leaders disapprove of smoking
70% of daily smokers agreed that there are fewer and fewer places where they feel comfortable smoking
90% of daily smokers agreed that being a non-smoker sets a good example to children

Anti-tobacco health information (doi: 10.5694/mja14.01628)

65% of smokers recalled often noticing pack warning labels in the past month
45% of smokers recalled often noticing anti-tobacco advertising or information in the past 6 months, most commonly on television
48% of smokers recalled ever noticing any targeted advertising or information featuring Aboriginal and Torres Strait Islander people or artwork in the past 6 months, with 16% noticing advertising or information featuring local people or artwork

Cessation support (doi: 10.5694/mja15.00293, 10.5694/mja15.00205)

75% of daily smokers who had seen a health professional in the past year had been advised to quit
37% of daily smokers had ever used nicotine replacement therapy or stop-smoking medicines, and 23% had used them in the past year
Among all smokers and ex-smokers who had quit ≤ 12 months before, nicotine patches were most commonly used (24%), followed by varenicline (11%) and nicotine gum (10%)

We also surveyed 645 staff at 31 Aboriginal community-controlled health services, including 374 Aboriginal and Torres Strait Islander staff who had a lower age- and sex-standardised prevalence of smoking compared with a national sample of the Aboriginal and Torres Strait Islander population (doi: 10.5694/mja14.01523).

A maple leaf among the gum trees

Longer obstacle courses may not produce better doctors

Intern training is now formally under scrutiny. As part of a review commissioned by the Australian Health Ministers’ Advisory Council (AHMAC) and led by Andrew Wilson and Anne Marie Feyer, a discussion paper was released in February this year that raised a number of questions and made a number of assumptions.1 That paper mentions the Canadian experience, and hence the internship described below is salutary.

One intern’s experience

Last year, one of the interns in my program in rural Victoria2 was a Canadian who had undertaken her undergraduate medical training in Australia. She had done so because, unlike in Canada, here she was not forced to make an irrevocable decision about her future career during her medical school years. She came from the prairie province, Saskatchewan. She had reasoned that early postgraduate years in Australia would give her “the breathing space” to make a more informed decision about the career she wanted to pursue.

However, she did not need the full year to decide. Near the end of her internship she made up her mind — she wanted to become a rural general practitioner in Canada. Complementing her hospital rotations in surgery, medicine and emergency medicine, she had undertaken extensive community practice through the combined 20-week rotation in the Victorian town of Bright and in the nearby Mount Hotham snowfields. This experience had sealed her intention.

In the snowfields, the exposure to medical emergencies and the number of trauma cases provided a busy and intensive learning experience. She was one of only two interns in Victoria licensed to take x-rays. The environment reminded her of Canada, and the experience was so rewarding that she needed no more time to sort out her career. Paradoxically, having such a wide variety of experience enhanced her ability to make a career decision early.

Her experience provided several insights.

First, the surgical, medical and emergency rotations provided worthwhile experience. She did not feel that she was being harnessed as cheap medical labour.

Second, in Canada with only 2 further years of training she will obtain her rural general practitioner certificate. Her intern year in Australia was recognised as part of her Canadian postgraduate training.

Third, one might ask: if the intern year satisfied the requirements for the first year of vocational training in Canada, why then would we encumber her in Australia, had she stayed, with a compulsory 4 years of vocational training before full registration? Turn the question around: does a well constructed intern year mean that vocational training could be shorter in Australia than it is at present?

Should hospital requirements come first?

The problem in Australia with not only the first but often the second postgraduate intern year is that the service requirements of hospitals have traditionally dominated the agenda. But if that service commitment is tempered by clear recognition of the educational value of these years, including community general practice experience as a component of a well constructed training program, then the first 2 intern years could surely contribute to specialty training programs.

The educational aspects of hospital-based programs for interns tend to abide by the requirements of the Australian Curriculum Framework for Junior Doctors (ACFJD). But the quality of an intern program should be defined by many features, including good organisation, innovative content, and the involvement of interested specialists, general practitioners, registrars and teachers who bring a high level of skills.

The Canadian intern appreciated the guidance and variety of experience of our program, which was innovative without infringing the ACFJD liturgy.

Longer is not necessarily better

The time taken to achieve a medical qualification is already long, but this has not stopped educators and others arguing progressively that more time is needed to achieve “full registration”, and then even more to achieve “independent practice”.

This phenomenon, which is as much sociological as economic, has been described in Social limits of growth by Fred Hirsch.3 Increasing the length of required education achieves social scarcity. It does not guarantee more skills and knowledge. Hirsch describes this as “the wasteful lengthening of the obstacle course”.

How might the intern years be made more useful for future practitioners?

The widespread introduction of a 20-week general practice rotation is a proposal worth exploring.2 Where it has been implemented, it has increased the complexity of organising training, but it has been warmly received by interns. They feel value has been added to their internship experience without making it longer. Were this to become more common, the role of directors of clinical training becomes critical in building and maintaining the bridge between community practice and the hospital environment.

The importance or otherwise of directors of clinical training is not canvassed in the AHMAC discussion paper1 — but it needs to be, as does the funding of such positions. Adequate supervision does not automatically follow just because the regulatory agencies deem it should be so. Nailing an Australian Health Practitioner Regulation Agency edict to the hospital board is not the solution. However, directors of clinical training who are appropriately resourced may be able to effectively interpret such edicts.

Nonetheless, innovation goes only so far, and funding is imperative for expanding internships into community practice. However, interns’ patients are ineligible to claim Medicare rebates directly. The Prevocational General Practice Placement Program used to provide funding, but that program has ceased. There has been no replacement.

When I graduated, I was unequivocally registered from Day 1. If translated into today’s world, that would mean eligibility for Medicare rebates for my patients. After all, the current intern already has a provider number; this is restricted to ordering tests, but what is the difference to allowing access to other areas of Medicare? If the government wants interns exposed to general practice then the government must pay for this experience, one way or the other.

In the end, the young Canadian doctor realised that she had had a firm base in generalist training. In Canada, she could progress more swiftly to a program tailored to be complementary. She also knew that it would take less time to complete her training. She has accepted a post in a small city in south-western Saskatchewan called Swift Current, where she will be able to put into practice what she has learned in Australia.

Lengthening time is not necessarily synonymous with acquiring greater expertise. What if one changed the metaphor and said expanding the time spent had a diluting effect? If so, further time spent in acquiring the right to practice independently without evidence as to its value could even have homoeopathic characteristics — perhaps like a drop of maple syrup into a firkin of eucalyptus oil.

Seeking a comprehensive approach to tobacco control for Aboriginal and Torres Strait Islander people

Tobacco smoking among Aboriginal and Torres Strait Islander people (hereafter we use the term “Aboriginal” to refer to both Aboriginal and Torres Strait Islander peoples, but do so with respect for the autonomy of the two peoples) is the leading cause of health inequities in this population, and its control is essential to “closing the gap” in health status between Aboriginal and other Australians.1 Australia, however, currently lacks a comprehensive framework that guides and monitors the effectiveness of tobacco control efforts among Aboriginal people at the local, state and national levels.

In a recent Australian study, the mortality rate for smokers over 45 years of age was three times higher than for non-smokers, and they died about 10 years earlier; two-thirds of deaths among smokers could be attributed to their smoking2 — and smoking accounts for 20% of all Aboriginal mortality.3 While smoking rates among Aboriginal people are decreasing, 42% of those aged 15 years or older reported smoking daily in 2012–2013 — more than 2.6 times the rate for other Australians.3 Of particular concern is that 39% of young Aboriginal people aged 12–24 years reported smoking daily,4 compared with 11% of young non-Aboriginal people.5 These data provide an insight into the substantial health gains that could be achieved were smoking rates among Aboriginal people reduced to the levels for non-Aboriginal Australians.1

“Talking About The Smokes”

The Talking About The Smokes (TATS) project for Aboriginal people complements recent efforts6–8 to tackle the problem of smoking in Aboriginal communities. The TATS project is a national collaborative study involving 34 Aboriginal community-controlled health services (ACCHSs), with over 2500 participants and 645 staff involved in 2012 and 2013. As part of the International Tobacco Control Policy Evaluation Project under the World Health Organization Framework Convention on Tobacco Control (FCTC), the TATS project aims to assess the impact of specific policies on smoking behaviour and attitudes. The TATS project found high levels of local knowledge about the risks of smoking.9 Most Aboriginal people who smoke wanted to quit,10 and about 70% had actually tried to quit. Aboriginal people in disadvantaged areas were less likely than others to want to quit,11 and many disadvantaged smokers who tried relapsed after a short time.12

The TATS project has highlighted the role of stress as a key driver of smoking behaviour among Aboriginal people.10 It led researchers to suggest that anti-tobacco messages be reframed to emphasise protecting others from passive smoke exposure, and that sustained targeted anti-tobacco advertising be ensured to reduce the social acceptability of smoking.13 The study has called attention to the importance of the role played by local community leaders as opinion leaders,14 the commitment of ACCHSs to reducing smoking,15 the role of health professional advice,11 and the need to improve access to nicotine replacement therapies.16 In particular, the TATS project emphasises the importance of broad comprehensive approaches to reducing exposure to passive smoke17 and to fighting causes of stress, such as poverty and racism.12

The TATS project provides important evidence about smoking behaviour and attitudes, and highlights the need for a broad approach to ensure the development of shared and consistent local, statewide and national strategies for reducing the high rates of smoking among Aboriginal people.12 The FCTC, endorsed by the National Preventative Health Taskforce,18accentuates upstream factors, such as regulating the exposure, costs and advertising of tobacco, as well as raising awareness and promoting effective quit programs.

Strategies for tobacco control

The United States Centers for Disease Control (CDC) has provided additional elements that could be adapted to establish a comprehensive framework for Aboriginal people in its Best practices for comprehensive tobacco control programs.19 The CDC guidelines focus on preventing smoking initiation in youths and young adults, promoting quitting, eliminating exposure to second-hand smoke and addressing tobacco-related disparities between different population groups. These aims are to be achieved through five overarching strategies:

State and community interventions that encourage and support tobacco-free norms, such as restrictions on marketing, smoking and sales, as well as reducing exposure to second-hand smoke by expanding smoke-free public spaces and workplaces.
Mass-reach health communication interventions that are sustained, targeted and culturally appropriate, and which reduce the number of young people who start smoking. The TATS project suggests these programs could involve community leaders, like programs developed in the Tackling Indigenous Smoking project.
Cessation interventions that provide culturally appropriate psychological support and take into account the critical role of stress, and which ensure access to effective pharmacological treatments and continuing support to prevent relapse.
Ongoing surveillance and evaluation, which is vital to ensuring programs are effective and modified as needed.
Considerable funding for infrastructure administration and management to sustain current successes and to implement further effective interventions. Current financial constraints create challenges for sustaining comprehensive tobacco control programs, with important programs having already lost funding.

A comprehensive framework to guide tobacco control could be used to pinpoint gaps in current and past strategies, as well as to identify areas for future research, policy and program development. This could include 3- to 5-year smoking strategies developed collaboratively with Indigenous leaders, ACCHSs and services at local, state3 and national levels, where efforts will be required over decades to reduce the pernicious impacts of smoking on Aboriginal health.

Changes in psychological distress and psychosocial functioning in young people visiting headspace centres for mental health problems

Improving the mental health and wellbeing of adolescents and young adults is receiving increasing attention throughout the world.1 The Australian Government was the first to invest significant funds in a practical and systematic response to this challenge, initiating a national reform process that created new service platforms for young people through its founding of headspace, the National Youth Mental Health Foundation.2

The initiative commenced in 2006, establishing an initial 10 centres and is set to increase to a network of 100 centres across Australia by 2016. headspace centres are one-stop entry points offering a mix of the services that young people need most. Centres provide early intervention by responding to early presentations of mental health problems and by assisting young people at greater risk of developing mental disorders. Being youth-friendly and non-stigmatising are priorities, and centre activities are founded on youth participation and engagement at all levels.3

From the beginning, the headspace initiative has evaluated its activities, despite the significant challenges inherent in determining the outcomes of such a complex, long-term, real-world, system-wide intervention. A preliminary external evaluation in 2009 showed that young people approved the approach used by the initial centres.4 At that time, however, it was still too early, in terms of implementation of the headspace initiative, to assess outcomes for the clients.

To facilitate investigation of the impact of the headspace centres, an innovative routine data capture system was introduced in 2013. This system collects information each time a young person accesses a headspace centre for service, and attempts to follow them up after they have finished engaging with the centre. Analysis of the dataset has shown that young people presenting to headspace centres have a wide range of mental health concerns, and are typically in the early stages of the development of a mental disorder.5 Further analyses have explored the types of service young people receive at the centres. In the companion paper to this article, we report that most of the young people seeking help at headspace centres present with mental health concerns, that they generally receive a timely response, and receive assessment and mental health care services. We also found that the initiative is primarily supported by funding from the headspace grant and by the Australian Government Medical Benefits Schedule.6

The current study reports the main clinical outcomes for young people who had presented to headspace centres for mental health concerns. The primary aim was to determine the extent to which psychological distress was reduced and psychosocial functioning improved in headspace clients.

Methods

Participants and procedure

Participants were all clients who had commenced an episode of care at a headspace centre for mental health reasons between 1 April 2013 and 31 March 2014. Young people who initially visited headspace for other reasons (situational, physical or sexual health, alcohol or other drug, or vocational reasons) were excluded from analyses. This selection was made because young people presenting with mental health concerns comprise the vast majority of those who seek help at headspace centres and definitely use their mental health care services; young people primarily presenting for other reasons may not have used mental health care services (see the companion paper to this article6). Analyses were limited to a young person’s first episode of care during the 12-month data collection period.

The procedure for the routine collection of data provided by the young people and service providers to the headspace Minimum Data Set is described elsewhere.5 Data related to psychological distress were collected from young people immediately before their first, third, sixth, 10th and 15th visits, as well as at follow-up. Measures of psychosocial functioning were recorded by service providers at each occasion of service.

Young people were invited to consent to being followed up when they first attended headspace. They provided an email address, and data were solicited after a 90-day pause in service provision by sending an email with a link to the follow-up questions. Young people could choose to answer these questions electronically, and responses were uploaded into the headspace data warehouse. Ethics approval for the follow-up was obtained from Melbourne Health Quality Assurance Review.

Measures

The primary presenting concern was categorised according to the clinical presentation features as determined by clinicians. These did not comprise diagnoses, but were rather the main symptoms evident at the initial presentation that were indicative of mental health problems.
Treatment services were recorded by clinicians, and were categorised as: cognitive behaviour therapy (CBT), interpersonal therapy, acceptance and commitment therapy, psychoeducation (including skills training and relaxation strategies), general and supportive counselling, mindfulness-based therapies, motivational interviewing, problem-solving therapy, and other interventions.
Client outcomes that were assessed were:
- the level of psychological distress, based on self-reports according to the 10-item Kessler Psychological Distress Scale (K10);7 and
- overall psychosocial functioning, assessed by service providers using the Social and Occupational Functioning Assessment Scale (SOFAS).8

Appendix 1 presents the number of clients for whom data were available at key time points.

Statistical analyses

IBM SPSS Statistics 21 was used for statistical analyses. Frequencies of each primary presenting concern were calculated, and age group and sex differences were assessed by χ2 analyses with Bonferroni correction for multiple comparisons.

Changes in each of the outcome measures over time were analysed in two ways.9 First, mixed-model repeated measures analysis of variance (ANOVA) was used to assess aggregate changes over time in K10 and SOFAS scores according to time point, number of service sessions, age group and sex. The statistical relationship between K10 and SOFAS scores was expressed as a Pearson product-moment correlation coefficient (r). Differences between the characteristics of clients who provided follow-up data and those who did not were analysed by logistic regression.

Second, significant change, reliable change and clinically significant change scores were calculated for the K10 and SOFAS data, as increasingly conditional indicators of change. The criterion for significant change was a moderate effect size (0.5) or greater for the degree of change.10 The reliable change index (RCI) (indicating reliable improvement or decline) and clinically significant change index (CSI) (cut-off point at which the person is more likely to belong to a non-clinical rather than a clinical population) were determined using Jacobson and Truax’s method.11

For the K10 scores, the RCI was estimated as a 6.73-point change (rounded to 7 points) using reliability coefficients reported for an Australian normative group (age group, 16–24 years) in the 2007 National Survey of Mental Health and Wellbeing.12 Using the same norms, the CSI cut-off was estimated to be 22.56 points (rounded to 23 points). For the SOFAS data, an RCI score of 10 was used; this was based on comparable outpatient psychiatric services data using the Global Assessment of Functioning scale as an equivalent. The CSI for the same comparison group was a score of 69 (Söderberg and Tungström [2006], cited by Falkenström13).

Results

The participants were 24 034 clients from the 55 headspace centres fully operational during the study period. Almost two-thirds of clients were female (62.7%), 36.9% were male and 0.4% were intersex or transgender. The mean age was 17.8 years (SD, 3.3), with 16.7% aged 12–14 years, 35.0% aged 15–17 years, 25.7% aged 18–20 years, and 22.6% aged 21–25 years.

Follow-up data were collected between June 2013 and August 2014. Of the total sample, 20 903 clients (87.0%) were eligible to provide follow-up data; the remaining 13.0% were still receiving headspace services or had not yet had a 90-day service-free period. Only 3.1% of eligible young people (651 clients) responded to the follow-up survey.

Presenting concern and treatment services

The most common mental health problems at initial presentation were depressive symptoms and anxiety, which together accounted for more than two-thirds of presentations. These were the most common presenting reasons for all age/sex groups, with the exception of 12–14-year-old boys, who presented most frequently with anxiety and anger problems and less frequently for depressive symptoms (Appendix 2).

Age and sex differences among those presenting with mental health concerns were indicated by χ2 analysis (χ2 [70] = 3300.57, P < 0.001). The proportions of younger males (12–14 years of age) presenting for anger or behavioural problems was greater than for other age/sex groups. Younger females (12–14 years of age) had higher presentation rates for deliberate self-harm than other groups (Appendix 2).

The most common treatment provided for all primary presenting concerns was CBT; for example, 43.6% of service provided to clients presenting with depressive symptoms involved CBT. A similar pattern of treatments was evident for all primary presenting concerns, with the second most common treatment being supportive counselling (except for borderline personality trait presentations). Psychoeducation was ranked third for most mental health problems (Box 1).

Mean changes in outcomes over time

Changes in the two outcome scores over time are depicted in Box 2 and Box 3. These plot the mean scores at each session that they were recorded, according to the total number of sessions attended. The sample sizes for each point declined as the number of sessions attended increased (Appendix 3). The follow-up data analyses were based on a particularly small sample size; further, no clinician-rated measures were available at this point, as the follow-up was based solely on self-report.

For the change in K10 between initial presentation and last recorded assessment, the factor with the greatest effect size was time, which explained 10.8% of the variance (Appendix 4, ANOVA 1; Box 2). Including the 3-month follow-up in the analysis showed that the time effect remained significant and explained 12.5% of the variance (Appendix 4, ANOVA 2). On average, there was a 3-point improvement in K10 scores from first to last assessment, and a further 3-point improvement from last service to follow-up for the small proportion of young people who provided follow-up data.

It is, however, important to note that the group of clients who provided follow-up data was significantly different from the much larger group of those who did not (χ2 [17] = 153.43, P < 0.001, Nagelkerke R2 = 0.062). Those who provided follow-up data were more likely to be female (odds ratio [OR], 1.63; 95% CI, 1.27–2.11), older (OR, 1.07; 95% CI, 1.04–1.11), have attended a greater number of service sessions (OR, 1.59; 95% CI, 1.39–1.82) and had better psychosocial functioning at exit (OR, 1.03; 95% CI, 1.02–1.05).

For change in SOFAS scores, time was again the strongest factor, but explained only 4.5% of the variance in this outcome measure Appendix 3, ANOVA 3; Box 3).

Significant, reliable and clinically significant change

The percentages of young people showing significant, reliable and clinically significant change between their first and last recorded assessments (not including follow-up) are presented in Box 4. Of the young people for whom data were available, psychological distress was significantly reduced in 36%, was reliably improved in 26%, and clinically significantly improved (by crossing the threshold distinguishing a clinical from a non-clinical population) in 21%. In 13% of clients, K10 scores significantly worsened, and in 8% they reliably deteriorated. According to clinician ratings of psychosocial functioning, significant and clinically significant improvement were each evident for 37% of the assessed clients, while 31% reliably improved. In contrast, function significantly declined in almost a fifth of clients, and reliably declined in 15%.

For 9957 clients, both K10 and SOFAS change data were available. Of these, 59.9% significantly improved and 49.2% reliably improved on at least one of the two scales, while 40.4% of those in the clinical group showed clinically significantly improvement on one or both of the scales.

It is important to note that the K10 and SOFAS scales measure different aspects of mental health, and that psychological distress (K10) was self-reported by young people, while social and occupational functioning (SOFAS) was assessed by a clinician. K10 and SOFAS scores were weakly correlated at presentation (r = − 0.19, P < 0.001) and at final assessment (r = − 0.23, P < 0.001).

There were statistically significant differences between those who improved and those who did not (significant improvement on at least one measure: χ2 [15] = 1168.48, P < 0.001, Nagelkerke R2 = 0.153). Improvement was predicted by greater distress (OR, 1.03; 95% CI, 1.02–1.04) and lower psychosocial functioning (OR, 0.94; 95% CI, 0.94–0.95) at service entry, and by attending a greater number of service sessions (OR, 1.16; 95% CI, 1.10–1.22). Age, sex and primary presenting concern did not predict improvement.

Discussion

This article reports the first outcome data for young people who have accessed the national headspace centre network for mental health problems. The analyses focused on the two key clinical outcomes, psychological distress and psychosocial functioning. The results show that psychological distress was significantly reduced in more than one-third of clients for whom data were available, and psychosocial functioning improved in a similar proportion. If improvement in either measure is considered, 60% of clients experienced significant change. Improvements in young people with greater distress and poorer functioning at service entry were noted in those who engaged well with the service (ie, attended more health care sessions). The findings are consistent with those reported from a single Sydney-based headspace service that found both symptomatic and functional improvements in its clients.14

Comparative data that would help determine whether these outcomes are acceptable are difficult to find. headspace clients present for a wide range of reasons and attend for varying numbers of sessions; although only outcomes for mental health clients were examined here, these young people still constitute a diverse group.6 Comparisons with outcomes from highly controlled clinical studies are therefore inappropriate. A study of psychotherapeutic outcomes in similarly aged young people attending a mental health clinic in the Netherlands, where the clients also presented with a variety of mental health concerns and received varying amounts of service, found that psychosocial functioning reliably improved in 19% of clients.13 This compares with the considerably higher rate of 31% that we have reported.

Comparative Australian data are scarce. Public tertiary mental health services use age bands of 0–17 and 18–64 years in their outcomes reports, and these are not comparable with either the age range of clients in these analyses or with the enhanced primary care service model of headspace. The most recent report from the National Outcomes and Casemix Collection (NOCC), which used the Health of the Nation Outcome Scales (HoNOS) family of outcome measures, showed that 37% of those aged 0–17 years and 24% of those aged 18–64 years using community-based public mental health services reported a significant improvement between the first and last occasions of service.15 The outcomes in young people reported here are similar to the child and adolescent results of the NOCC report, but much better than its findings for adults. However, the degree to which HoNOS outcomes are comparable with K10 and SOFAS scores is unclear, and the lack of directly comparable age groups makes interpretation difficult.

Drawing conclusions from the current study is restricted by several limitations. Primarily, the absence of a control group and other limitations inherent to observational studies means that the changes in scores reported cannot be attributed to headspace care.16 Further, most of the outcome data were derived from the last recorded assessment point for each client, but for many young people this was not at the completion of treatment. Our results are therefore likely to underestimate psychological and psychosocial gains in the course of treatment.

The follow-up rate was disappointing, although wholly expected, and highlights the considerable challenges in persuading young people to provide follow-up information after they have stopped attending for service. Without committing substantial resources to maintaining contact with people after leaving a health service, obtaining longer-term outcomes from real-world interventions will always be a major hurdle. Nevertheless, the headspace initiative has developed a process that attempts to routinely follow up young people after the end of service, and this may be unique in service delivery outside a well resourced prospective clinical trial. Over time, this follow-up database will grow and yield a rich source of information, even though there will be inevitable bias in those who provide follow-up data.

Another limitation is that the data cannot clearly determine the extent to which headspace clients received sufficient and appropriately matched “doses” of evidence-based therapies for different presenting problems and diagnoses, although it is evident that most clients did receive evidence-based therapies. headspace centres differ considerably in both their priorities and their capacity as a result of the diverse community and workforce contexts in which they are embedded,17 although all centres pursue a common vision of youth-focused, evidence-based, early intervention.3 The complexity and severity of young people’s presenting concerns also varies, with a substantial subset of young people who need, but are unable to gain, access to specialised tertiary services,18 which may have an impact on average improvement scores for the total client group.

Nevertheless, this article demonstrates that headspace is committed to examining and reporting outcomes for young people using its services, and that the headspace centre initiative is associated with improved mental health outcomes for a large number of young people assisted by this network across Australia.

1 Most common types of mental health care service received by headspace clients, according to the primary presenting problem*

Total sessions

Treatment services type rank

Presenting concern

Depressive symptoms

25 708

CBT
(43.6%)

Supportive counselling
(18.6%)

Psycho-education
(8.2%)

IPT
(7.5%)

ACT
(4.8%)

Anxiety symptoms

21 516

CBT
(47.0%)

Supportive counselling
(14.6%)

Psycho-education
(9.7%)

ACT
(7.5%)

IPT
(4.9%)

Anger problems

3859

CBT
(36.7%)

Supportive counselling
(21.3%)

Psycho-education
(16.6%)

IPT
(6.8%)

Motivational interviewing
(3.3%)

Stress related

3521

CBT
(34.0%)

Supportive counselling
(21.9%)

Psycho-education
(12.1%)

IPT
(7.2%)

ACT
(5.5%)

Suicidal thoughts or behaviour

2355

CBT
(36.9%)

Supportive counselling
(19.5%)

IPT
(9.6%)

Psycho-education
(9.2%)

ACT
(5.1%)

Behavioural problems

1389

CBT
(32.1%)

Supportive counselling
(23.3%)

Psycho-education
(18.8%)

IPT
(4.7%)

ACT
(3.6%)

Deliberate self-harm

1479

CBT
(36.3%)

Supportive counselling
(22.4%)

Psycho-education
(11.8%)

IPT
(6.6%)

ACT
(5.8%)

Eating disorder related

1159

CBT
(47.9%)

Supportive counselling
(12.9%)

Psycho-education
(8.4%)

IPT
(7.1%)

ACT
(6.0%)

Psychotic symptoms

531

CBT
(33.5%)

Supportive counselling
(23.0%)

Other
(18.8%)

Psycho-education
(12.2%)

IPT
(7.9%)

Borderline personality traits

523

CBT
(31.4%)

Other
(18.2%)

Supportive counselling
(17.8%)

Psycho-education
(11.1%)

IPT
(7.6%)

All presenting concerns

63 221

CBT
(42.8%)

Supportive counselling
(17.9%)

Psycho-education
(9.9%)

IPT
(6.5%)

ACT
(5.6%)

CBT = cognitive behaviour therapy. IPT = interpersonal therapy. ACT = acceptance and commitment therapy.

* Percentages refer to proportion of total mental health care sessions received by clients presenting with the respective concern. Percentages in rows do not add to 100% as other treatment modes were possible.

2 Mean psychological distress scores (K10) at different time points

3 Mean psychosocial functioning scores (SOFAS) at different time points

4 Proportion of young people showing significant, reliable and clinical change in psychological distress and psychosocial functioning between first and last service ratings

Measure	Method	Number of clients	Change category
Measure	Method	Number of clients	Improvement	No change	Deterioration
K10	Significant change (effect size ≥ 0.5)	10 228	36.1%	50.9%	13.0%
	Reliable change	10 228	26.2%	65.9%	8.0%
	Clinically significant change*	8205	21.1%	78.9%	NA
SOFAS	Significant change (effect size ≥ 0.5)	15 496	37.1%	43.4%	19.5%
	Reliable change	15 496	30.9%	53.6%	15.5%
	Clinically significant change*	9556	37.0%	63.0%	NA

K10 = Kessler Psychological Distress Scale. SOFAS = Social and Occupational Functioning Assessment Scale. NA = not applicable: young people in the clinical population are, by definition, not able to deteriorate, but rather remain in the clinical population. * It was not possible to assess the clinical improvement of young people who were in the non-clinical population at the first time point (19.8% of total sample for K10 and 38.3% of total sample for SOFAS); they were therefore excluded from this analysis.

Response – The Royal Australasian College of Physicians: a 21st century college

This article is a response by the Royal Australasian College of Physicians (RACP) to an article in this issue of the Journal: Komesaroff PA, Kerridge IA, Isaacs D, Brooks PM. The scourge of managerialism and the Royal Australasian College of Physicians. Med J Aust 2015; 202: 519-521. The RACP was made aware only recently of the article, which was submitted to the Journal some time ago. Due to this unique circumstance, a rapid and simultaneous response to the article is provided in this issue of the MJA. Publication of this response should not be taken as creating a precedent at the MJA.

Editorial Advisory Committee:
Charles Guest MPH, PhD, FAFPHM
Bruce Waxman FRACS, FRCS, MRACMA
Jeffrey Zajac PhD, FRACP
Charles Guest and Jeffrey Zajac declare that they are members of the RACP.

A statement from the Royal Australasian College of Physicians

One of the great lessons of the 20th century was the danger of ideologies that attempted to squeeze the complexity of the world into their frameworks.

The authors of “The scourge of managerialism and the Royal Australasian College of Physicians”1 have fallen into this trap by attempting to portray as a “corporatisation” framework a series of structural changes being undertaken to make the Royal Australasian College of Physicians (RACP) more focused on the needs of its members.

Komesaroff and colleagues argue that the College is victim to a takeover from a faceless class of managers and technocrats. Proposals for a more streamlined Board and a College Council that bring our disparate specialties together are characterised as markers on the road to a neoliberal dystopia.

The fundamental flaw in the article is that it provides little attention to facts that do not fit in with its argument. In portraying the College’s role as “providing a forum for physicians to communicate with each other”, it largely overlooks the objectives of the College that demand it be and remain an outward-looking institution committed to maintaining the highest professional standards, delivering robust training to its 6000 trainees and publicly advocating for the health of the public.

How does the authors’ analysis that the College has been captured by faceless managers account for the Australian Medical Council’s recent decision to award the College 6 years’ accreditation as the sole trainee of specialist physicians in Australia and New Zealand? Why would these supposed disciples of Thatcher and Reagan be allowing such a progressive advocacy agenda? At our recent Congress, the RACP adopted a progressive and controversial policy on asylum seekers; embraced the complexity of medicinal marijuana and end-of-life care; and grappled with confronting issues like gender identity and Indigenous health. The Board recently voted to divest investments identified as being directly and materially involved in fossil fuel activities.

And how does an analysis about managerial control account for the many Fellow committees that directly shape the College, or the current proposal to create an influential and representative College Council that will provide a forum to bring together our disparate specialties to share insights, collaborate and drive our broader agenda? The article’s portrayal of reforms championed by the Board needs to be challenged. While a minority resisted the constitutional changes proposed in 2013, a two-thirds majority supported the proposals.

These facts are paid little attention because they get in the way of what appears to be an ideological critique of the College, its Board and its dedicated and professional staff.

The reality is that this College, far from embracing “corporatism”, is following the lead of member-based non-for-profit associations around the world and rethinking the way it is run — focusing on the needs of our members, especially those entering the profession, harnessing technology, reviewing our committees and services to ensure they remain relevant. We cannot work to a collective vision if we do not empower a democratically elected Board to set a strategy and implement it. Change upsets people, but the risk of not changing is that an organisation will become irrelevant because of pressing external challenges.

If the College were to be accused of pursuing any ideological theory or agenda it would be that of “empowerment”. Empowerment is how we engage our more than 22 000 members to train the next generation of physicians, nurture their careers and make a difference as leaders in our communities. That may not be as dramatic a story as a sinister corporate takeover of the College, but it’s one that the College believes in for the benefit of our current and future Fellows and trainees, and for the communities they serve.

The services provided to young people through the headspace centres across Australia

headspace, the National Youth Mental Health Foundation, was initiated by the Australian Government in 2006 because it was recognised that the prevalence of mental disorders and the burden of disease associated with mental health problems was greater for those in their adolescent and early adult years than in older adults, but that young people were less likely to access professional help.1 headspace centres aim to be highly accessible, youth-friendly integrated service hubs that respond to the mental health, general health, alcohol and other drug, and vocational concerns of young people aged 12 to 25 years.2 The main goal is to improve mental health outcomes by reducing help-seeking barriers and facilitating early access to services that meet the holistic needs of young people. Recent data indicate that the initiative is largely achieving its aim to improve access to services early in the development of mental illness.3

As the headspace network has grown, the key components of the model have become clearer.4 At the heart of all headspace services is a youth-friendly, non-stigmatising, inclusive “no wrong door” approach, essential for engaging young people in mental health care.5 This is both a challenge and a major point of difference from other mental health services, which are often highly targeted, with clear exclusion criteria. Consequently, there has been a high level of demand for the services offered by headspace.3Centres have been set up across Australia in highly diverse community settings with a flexible local capacity for service delivery. The variation in focus between centres and in the types of services they offer has been noted as both a strength and a concern.6 Workforce problems are an ongoing challenge for many centres, particularly in rural and remote locations.7

headspace aims to provide a timely and appropriate response to the various problems presented by young people, and to provide a soft entry point to mental health care. In this study we set out to investigate what services headspace centres are providing to young people and how they are being delivered. The proportions of young people who initially presented in each of the main service streams — mental health, situational, physical health, alcohol and other drugs, and vocational health — were determined, as were the numbers of clients who received mental health care at headspace centres after initially presenting to the service for other reasons. We examined the waiting time for services, patterns of service use (number of sessions of each service type attended, types of service mix), as well as the major providers and the funding streams that support service delivery.

Methods

Participants and procedures

All participants had commenced an episode of care at a headspace centre between 1 April 2013 and 31 March 2014.

Data were drawn from the headspace Minimum Data Set,3 which includes the routine data collected from all clients who provide consent, producing a near-complete census of headspace clients. Young people enter data into an electronic form before each service visit, and service providers also submit relevant information about each visit. Data were de-identified by encryption and extracted to the headspace national office data warehouse.

Ethics approval was obtained through internal quality assurance processes; these consent processes were reviewed and endorsed by an independent body, Australasian Human Research Ethics Consultancy Services. Follow-up data collection was approved by Melbourne Health Quality Assurance.

Measures

The main presenting problem or concern was categorised by the service provider as: mental health or behavioural (symptoms of a mental health problem); situational (eg, bullying at school, difficulty with personal relationships, grief); physical or sexual health; alcohol or other drugs (AOD); vocational; or other.
The service type was categorised as one of the following on each occasion of service: mental health; physical or sexual health; AOD; vocational; or engagement and assessment. The number of sessions of each main service type attended by a young person during the data collection period was calculated.
The wait time was measured by asking clients how long they had waited after requesting an appointment for their first service appointment, and whether they thought they had been required to wait too long.
Service providers were categorised by profession and role. This included intake and youth workers, psychologists, allied mental health workers (social workers, mental health nurses and occupational therapists), general practitioners, nurses, psychiatrists, AOD workers, vocational workers, clinical leads and administrative staff (including reception staff, managers and practice managers).
The funding stream was categorised as: the headspace grant (each centre is funded through a headspace grant); the Medicare Benefits Schedule (MBS); Access to Allied Psychological Services (ATAPS); the Mental Health Nurse Initiative (MHNI); Rural Primary Health Services (RPHS); in-kind contributions by partner organisations; or other.

Results

Data were assessed for 33 038 young people who had commenced an episode of care at one of 55 established headspace centres during the study period; 16.8% were aged 12–14 years, 34.4% aged 15–17 years, 25.8% aged 18–20 years, and 23.0% were 21–25 years of age. Most were female (61.9%); 37.5% were male.

Main presenting problems or concerns

The proportions of young people who attended headspace centres for each category of main presenting problem or concern and the number of service sessions they attended are shown in Box 1. Almost three-quarters of presentations specifically involved mental health and behavioural problems; 13.4% were for situational problems and 7.1% for physical or sexual health concerns. Only a small proportion (3.1%) presented primarily for AOD problems, and very few (1.8%) for vocational reasons.

The vast majority of clients, regardless of their initial problem or concern, attended mental health sessions; this included almost all who presented with situational or AOD problems, and almost 85% of those who presented with a vocational problem. The exception was that less than half of those who presented with physical or sexual health concerns also used mental health services.

Clients who first presented for mental health reasons attended the most service sessions, with an average of 4.4 and a median of 3.0 sessions per person. More than a quarter of these young people attended six or more sessions, and more than 10% attended 10 or more. Less than a third attended only once for mental health consultations.

Those who first presented for a physical or sexual health problem attended the fewest service sessions.

Wait time

Most of the young people reported that they did not wait too long for their first appointment (Box 1).

According to their detailed responses, 38.9% of clients had waited less than one week for their first appointment, 41.2% for 1–2 weeks, 14.6% for 3–4 weeks, and only 5.3% had waited more than 4 weeks. Unsurprisingly, almost half of those who had to wait more than 4 weeks reported that they had waited too long.

Service mix

headspace clients typically attend at least one session of engagement and assessment, except those who present primarily for physical or sexual health problems. The time used for engagement and assessment increased with the total number of sessions attended, regardless of the initial presenting problem (see Appendix).

Box 2 shows the proportions of each type of service provision for each of the core streams accessed by clients with different initial reasons for presenting. These data show the strong similarity in service patterns for those who presented with mental health and situational problems. Young people who first presented with situational concerns received slightly more engagement and assessment, but were otherwise similar to those who presented with mental health problems.

Young people presenting with physical or sexual health problems had quite a different pattern to those presenting with other concerns, although there was still a large component of engagement and assessment and mental health treatment. Young people who presented for AOD problems tended to have a greater need for engagement and assessment.

Service providers and funding streams

The service providers that delivered most of each service type are shown in Box 3A. In line with the headspace service model — young people usually have an engagement and assessment session with an intake or youth worker during their initial appointment to gather information and to determine their needs — intake and youth workers provided almost half of the engagement and assessment service, followed by psychologists, who delivered almost 20%. Other allied mental health workers, including social workers and occupational therapists, provided just over 12%.

Mental health services were mostly delivered by allied mental health professionals (81%), with over half provided by psychologists; only 1.2% was provided by psychiatrists, and just over 10% by general practitioners. Almost all physical or sexual health service was provided by GPs or nurses. Specialist AOD workers undertook a third of AOD service, complemented by contributions from allied mental health workers. The small amount of vocational service was largely provided by specialised vocational workers, although a quarter was undertaken by intake and youth workers.

The provision of headspace services relies on a number of funding streams. The major sources for each service type are compiled in Box 3B. Engagement and assessment services were mostly funded by the headspace grant (71%) or through the MBS (21%). Nearly two-thirds of mental health services were funded by the MBS and a smaller contribution by the ATAPS program, with just under a third funded by the headspace grant. Physical and sexual health services were primarily funded through MBS items, but 22% was supported by headspace grant funds. In contrast, the main funding source for AOD and vocational services was in-kind support by co-located services or consortium partners.

It should be noted that there was variation between headspace centres in each of the parameters discussed here, but space precludes the presentation of detailed analyses. Generally, however, no major differences were associated with the size, age or geographical location of centres. The one exception was waiting too long; significantly fewer young people reported waiting too long at the most recently established centres than at centres established during the first three rounds of the headspace program (7.0% v. 10.6%; P < 0.001). The longest wait times were experienced in one large centre in a major city, where 27% of young people reported they had waited too long, compared with only 2% at each of a small inner regional and a medium-sized outer regional centre. Waiting too long was significantly more common at large centres (12.0%) than at medium (9.6%) and small (9.4%) centres (P < 0.001). It was also significantly more frequent in major cities (11.9%) than at inner regional, outer regional and remote centres (8.3%, 9.2% and 8.1%, respectively; P < 0.001).

Discussion

There is considerable interest in the headspace initiative because it comprises a significant investment by the Australian Government in an innovative approach to youth mental health. The results presented here show that the vast majority of young people specifically attend headspace centres for mental health problems, and that the next most common reason for attendance involves situational problems that affect the wellbeing of the young person, such as bullying at school, difficulty with personal relationships or grief. This is consistent with the general early intervention aim of the headspace initiative, and with the recognition that mental health problems and related risk factors are the primary health concerns for adolescents and young adults.8

A sizeable minority of young people initially attended headspace for physical or sexual health problems. For almost half of these clients, this led to a mental health consultation, supporting the contention that physical and sexual health care can and should be a pathway to mental health care (and vice versa).

The headspace initiative engages young people with a range of health and wellbeing concerns, not just those with mental health problems. Few clients, however, presented primarily for AOD problems and vocational difficulties, suggesting that these are more often accompanying problems than primary concerns for those attending headspace centres, although half of the headspace clients aged 17–25 years are looking for work (compared with less than 10% for this age group in the general population).9 Funding for these two core streams relied primarily on in-kind contributions by headspace service partners, emphasising the value of the local partnership model that underpins service delivery, but also revealing vulnerability in terms of stable funding. Building the capacity of the headspace model to better support young people with vocational needs and secondary AOD problems should be a priority.

As young people are often reluctant to attend mental health services, receiving an appointment promptly after a young person has decided to seek help is crucial. The vast majority of headspace clients waited 2 weeks or less for initial service, a notable achievement. Wait times are a major barrier in traditional mental health services,10 and minimising waiting is a distinguishing focus of headspace. Nevertheless, some clients waited longer, and wait times were longer in more established centres. Minimising wait times must remain a constant focus for headspace services, while continuing to respond to the growing demands of young people with a range of presenting problems. Engagement and assessment are also critical elements.

Australia claims to lead the world in innovative approaches to youth mental health care. Our results confirm patterns that diverge from traditional mental health service delivery, and we argue that these patterns are more appropriate for meeting the social and mental health needs of young people.5

1 Number of headspace service sessions attended (all types) and initial wait time for young people presenting with different categories of problem or concern

		Main reason for presenting to headspace
	All clients	Mental health and behaviour	Situational	Physical or sexual health	Alcohol or other drugs	Vocational

Number of presentations (% of all clients)	33 038†	24 034 (72.7%)	4440 (13.4%)	2332 (7.1%)	1030 (3.1%)	583 (1.8%)
Number who received mental health service (% of presentations for respective reason)*	31 134 (94.2%)	23 738 (98.8%)	4331 (97.5%)	1134 (48.6%)	951 (92.3%)	493 (84.6%)

Mean number of sessions attended (SD)	4.1 (4.2)	4.4 (4.4)	3.6 (3.7)	2.5 (2.9)	3.0 (3.4)	3.2 (3.6)
Median number of sessions attended	3.0	3.0	2.0	1.0	2.0	2.0
Number of sessions attended
1 session	35.4%	32.1%	39.0%	50.8%	45.2%	45.5%
2 sessions	14.0%	12.8%	14.8%	22.2%	19.3%	16.1%
3–5 sessions	25.6%	26.7%	25.7%	18.7%	21.0%	22.3%
6–9 sessions	15.1%	16.9%	13.3%	4.6%	10.0%	9.8%
10 or more sessions	10.0%	11.5%	7.2%	3.6%	4.6%	6.3%

Client did not wait too long for first service	89.4%	88.7%	91.5%	90.9%	91.4%	92.1%

* Includes engagement and assessment services. † Includes 619 young people (1.9% of sample) who had presented for “other” primary reasons not included in the five major categories, such as attention deficit and developmental disorders.

2 Service mix according to initial presenting problem or concern

3 Main service providers (A) and main funding sources (B) for each headspace service type*

(A)

Main types of service providers (rank)

Service type

Engagement and assessment

Intake/youth worker
(46.4%)

Psychologist
(18.6%)

Allied mental health
(12.2%)

GP
(7.4%)

Mental health

Psychologist
(50.6%)

Allied mental health
(17.2%)

Intake/youth worker
(13.2%)

GP
(11.5%)

Physical or sexual health

GP
(76.1%)

Nurse
(11.7%)

Alcohol or drugs

AOD worker
(31.4%)

Allied mental health
(31.4%)

Intake/youth worker
(13.2%)

Psychologist
(10.3%)

Vocational

Vocational
(38.4%)

Intake/youth worker
(24.7%)

Miscellaneous†
(16.5%)

Psychologist
(8.2%)

(B)

Main funding sources (rank)

Service type

Engagement and assessment

headspace
(70.8%)

MBS
(20.9%)

Mental health

MBS
(57.4%)

headspace
(29.5%)

ATAPS
(7.8%)

Physical or sexual health

MBS
(69.3%)

headspace
(21.8%)

In-kind
(6.7%)

Alcohol or drugs

In-kind
(50.3%)

headspace
(28.6%)

MBS
(17.8%)

Vocational

In-kind
(46.8%)

headspace
(37.2%)

MBS
(11.7%)

AOD = alcohol or drugs; ATAPS = Access to Allied Psychological Services; GP = general practitioner; MBS = Medical Benefits Scheme.

* A maximum of four service providers and three funding sources are reported here; contributions under 5% are not included. For these reasons, rows do not add to 100%.

† Consisting of various types of provider, mainly interns and placement, community engagement and education officers.

Smoking among a national sample of Aboriginal and Torres Strait Islander health service staff

In 2012–2013, the prevalence of daily smoking among Aboriginal and Torres Strait Islander adults was 42%, although it is falling.1 For many years it has been suggested that the high smoking prevalence of Aboriginal health workers (AHWs) is a barrier to reducing smoking in the communities they serve.2,3 AHWs and other Aboriginal and Torres Strait Islander health service staff are role models and advocates for health in their communities, and there is evidence that AHWs who smoke have been less likely than those who do not to assist or promote smoking cessation.2

The high prevalences of smoking previously reported among AHWs or other Aboriginal and Torres Strait Islander health service staff do not differ greatly from the high prevalences in their communities, but are based on small samples.3 Similarly high smoking prevalence among doctors has been reported in some developing countries, raising the same concerns about their roles in supporting cessation and as opinion leaders.4 In contrast, there has been a steady decline in smoking prevalence among doctors in most developed countries — in Australia, this fell from 27% in 1964 to 3% in 1997, much lower than in the general Australian population.5,6

It has been asserted that smoking prevalence starts to fall earlier among doctors than among the general population as doctors are more likely to recognise the health consequences and change normative beliefs, and also become aware of the contradiction between their smoking and their role in improving health.7 The low smoking prevalence found among doctors is seen as an achievable future for the entire population.8

Here, we compare smoking prevalence, quitting activity and beliefs among a national sample of Aboriginal and Torres Strait Islander staff at Aboriginal community-controlled health services (ACCHSs) and among members of their communities who smoke.

Methods

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people in the communities served by 34 ACCHSs and one community in the Torres Strait between April 2012 and October 2013. At the same time, all staff at 31 of these ACCHSs were invited to complete a self-administered survey. Staff surveys were requested but not completed at four of the 35 project sites, owing to other local priorities.

The TATS project has been described elsewhere.9 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness, using a quota sampling design. At each site, we aimed to survey 50 smokers (or ex-smokers who had quit ≤ 12 months previously) and 25 non-smokers from the community served by the ACCHS, with equal numbers in the smoking and non-smoking samples of men and women, and of those aged 18–34 and ≥ 35 years. In four large city sites and in the Torres Strait community, the sample size was doubled.

Staff surveys were paper-based at 20 ACCHSs and online at seven, with four offering both options. Surveys took 5–10 minutes to complete and included questions from the main community survey about smoking and quitting behaviour and attitudes, exposure to advertising, and use of cessation support. These were supplemented by questions about smoking at work, the respondent’s role at the ACCHS, and smoking and cessation beliefs related to his or her role. The questions used in this article are listed in Appendix 1.

In contrast to the staff surveys, trained local interviewers completed the 30–60-minute survey of community members face to face using a computer tablet. A single survey of health service policy and activities was also completed by key informants at each site.

We compared the smoking status of Aboriginal and Torres Strait Islander staff with data from the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The NATSISS was a national, stratified, multistage, random, face-to-face household survey with 7163 Aboriginal and Torres Strait Islander participants aged 18 years and over conducted by the Australian Bureau of Statistics from August 2008 to April 2009, with an 82% response rate.10

We also compared the responses to questions about smoking and cessation practices and attitudes of Aboriginal and Torres Strait Islander staff who smoked with those of smokers in the community survey. We assessed differences in quitting and use of stop-smoking medications between staff who had active support from the health service to quit and those who did not.

Statistical analyses

All comparisons of staff responses with the responses in the 2008 NATSISS or in the main community survey were directly standardised to the distribution of the age, sex and remoteness of either smokers or the total Aboriginal and Torres Strait Islander population in the 2008 NATSISS. As it not possible to estimate sampling error in non-probabilistic quota samples, we do not report confidence intervals around our prevalence estimates and only report percentages to the nearest integer.

The association between dichotomous variables within our samples was assessed using simple logistic regression to generate odds ratios (ORs) and P values based on Wald tests, and using χ2 tests for other categorical variables. These results were analysed using Stata 13 (StataCorp) [SVY] commands to adjust for the sampling design (using site clusters in both the staff and community surveys, and age–sex quotas in the community survey as strata). NATSISS data were analysed using replicate and person weights as previously described.11

Except for attitude questions, where “don’t know” responses were combined with “neither agree nor disagree”, reported percentages and frequencies exclude participants not answering, answering “don’t know”, or for whom the question was not applicable. For the question about levels of confidence in talking to others about their smoking, we reported those who answered “don’t know” but excluded 7% who did not answer. Less than 5% of responses were excluded for all other questions analysed in this report, except for those in the staff survey about health service support of quit attempts (7%), whether the last quit attempt was before or after being employed at the health service (8%) and whether a quit attempt had been made in the past year (13%).

Results

Surveys were completed by 645 staff at 31 ACCHSs, covering every state and territory as well as major cities and regional and remote areas (Appendix 2). As it was deemed impractical to precisely estimate total staff numbers, we have no precise response rate. However, it is unlikely to be above 50%, as 215 surveys were completed at 17 services with up to 50 staff (mean, 12.6 surveys per ACCHS) and 430 at 14 services with more than 50 staff (mean, 30.7 per ACCHS).

Fifty-eight per cent of respondents (374/641) were Aboriginal or Torres Strait Islander people (Appendix 2). Of the Aboriginal and Torres Strait Islander staff, 76% (286/374) were women, 48% (173/362) had been at the ACCHS longer than 2 years, 88% (319/362) worked full-time, 49% (181/367) were AHWs or community workers, 5% (18/367) were doctors or nurses, 25% (92/367) were in other roles with direct client contact, 21% (76/367) had no contact with clients, and 17% (63/368) were in managerial roles.

Of the Aboriginal and Torres Strait Islander staff, 146 were smokers. None of those who smoked said they did so indoors at work, and 13% (19/145) said they did not smoke at work. Most (57%, 83/145) said they smoked outside the health service boundary or fence. In the past month, 41% (59/145) had smoked where ACCHS clients could see them. While 77% (111/145) had smoked with co-workers during work hours in the past month, only 28% (40/145) had smoked with clients of the ACCHS. All ACCHSs had a smoke-free policy or rules. Most Aboriginal and Torres Strait Islander staff who smoked (74%, 107/144) agreed that being a non-smoker sets a good example to patients at their health service.

Comparison of Aboriginal and Torres Strait Islander staff with NATSISS participants

Compared with all Aboriginal and Torres Strait Islander adults in the 2008 NATSISS, a lower standardised proportion of Aboriginal and Torres Strait Islander ACCHS staff smoked (38% v 49.8%), with more having never smoked and a similar proportion of ex-smokers (Box 1). The difference in the proportion of smokers was smaller when ACCHS staff were compared only with employed adults in the NATSISS (38% v 44.8%). Staff who had ever smoked were more likely than their NATSISS counterparts to have successfully quit (38% [88/234] v 30.1% [95% CI, 28.0%–32.1%]). Most of the staff ex-smokers (62%, 50/81) had quit before they started working at the health service.

Comparison of Aboriginal and Torres Strait Islander staff with community members

A greater standardised proportion of Aboriginal and Torres Strait Islander smokers among the staff than among other community members had ever made a quit attempt (83% [118/144] v 70% [1143/1631]; OR, 2.1 [95% CI, 1.1–3.7]; P = 0.02). However, the difference in the proportion of smokers who had made a quit attempt in the past year was not statistically significant (staff v community, 58% [67/127] v 50% [796/1609]; OR, 1.4 [95% CI, 0.81–2.4]; P = 0.24).

There were significant differences in how many of the respondent’s five closest family or friends smoked, with staff smokers having lower odds than community smokers of reporting all five were smokers (OR, 0.56; 95% CI, 0.34–0.94; P = 0.03). Staff who smoked had significantly greater odds of having often or very often noticed advertising about the dangers of smoking or that encouraged quitting in the past 6 months, compared with other community members who smoked (OR, 2.8; 95% CI, 1.4–5.6; P = 0.004) (Box 2).

Compared with community smokers, a significantly higher proportion of Aboriginal and Torres Strait Islander staff smokers who had ever made a quit attempt had used nicotine replacement therapy (NRT) or other stop-smoking medications, (OR, 3.0; 95% CI, 1.6–5.7; P = 0.001). Significantly higher proportions of staff reported use of NRT patches (OR, 2.8; 95% CI, 1.5–5.2; P = 0.003), NRT tablets (OR, 3.3; 95% CI, 1.2–9.7; P = 0.03), varenicline (OR, 6.1; 95% CI, 2.9–12.8; P < 0.001) and bupropion (OR, 6.6; 95% CI, 2.5–17.2; P < 0.001) (Box 2).

Nearly half of the staff smokers who had made a quit attempt (47%, 52/111) had at least one of these attempts actively supported by the health service, most commonly through an information session for staff (n = 20) or access to free or subsidised NRT (n = 19). A higher proportion of staff who had health service support in their quit attempts, compared with those who did not, had ever used NRT or other stop-smoking medications (79% [41/52] v 46% [27/59]; OR, 4.4; 95% CI, 1.9–10.4; P = 0.001). However, staff from health services that reported providing additional cessation support for staff did not have significantly greater odds of making a quit attempt in the past year than those whose service did not (56% [46/82] v 47%, [21/45]; OR, 1.5; 95% CI, 0.65–3.3), although statistical power to detect a significant effect was low.

There were significant differences between staff smokers and community smokers in how much they believed they would benefit if they were to quit smoking in the next 6 months (P = 0.03) (Box 3); staff had non-significantly greater odds of reporting they would benefit very much or extremely (OR, 1.95; 95% CI, 0.92–4.2; P = 0.08). Smokers’ risk-minimising beliefs and beliefs about the dangers of second-hand smoke were similar among staff and other community members (Box 3). Most staff smokers (58%, 85/146) agreed that staff and managers of the health service disapproved of smoking, with only 12% (18/146) disagreeing with this.

For Aboriginal and Torres Strait Islander staff who had direct contact with ACCHS clients, there was a significant association (P < 0.001) between their smoking status and whether they felt confident talking to others about smoking and quitting (Box 4). Ex-smokers were significantly more likely than smokers to report being very much or extremely confident (OR, 4.3; 95% CI, 2.2–8.3; P < 0.001).

Discussion

Our results suggest that Aboriginal and Torres Strait Islander staff of ACCHSs have a lower smoking prevalence than other Aboriginal and Torres Strait Islander people. However, our estimate of staff smoking may be falsely low, as our response rate was not high and smokers may have been less likely to complete our survey.

Our national estimate of staff smoking prevalence was at the lower end of previous smaller local and regional studies, and much lower than the largest previous study (51%, n = 85), which also reported the highest (but still a modest) response rate of 63%.3,12 However, these studies concentrated on AHWs (variously defined) rather than all Aboriginal and Torres Strait Islander staff. In spite of the supportive environment at the ACCHSs, Aboriginal and Torres Strait Islander staff in our survey were still much more likely to smoke than either Australian doctors or other health professionals in similar countries.6,13 As in previous research with AHWs, and with other health professionals in other settings, we found that staff who smoked were less confident in talking about quitting. This remains a concern and a rationale for assisting Aboriginal and Torres Strait Islander smokers to quit, and may support preferential employment of non-smokers.5,14

The lower smoking prevalence among Aboriginal and Torres Strait Islander staff of ACCHSs was similar to the lower smoking prevalence among other employed Aboriginal and Torres Strait Islander people surveyed in the NATSISS, and was mainly due to more staff having never smoked (rather than more being ex-smokers).

Most of the ACCHS staff who still smoked agreed that being a non-smoker sets a good example to patients. Fewer Aboriginal and Torres Strait Islander staff reported smoking with patients than with co-workers at work, and most did not smoke where they could be seen by patients, suggesting they accept this responsibility as a role model. In contrast, research conducted in 2009–2010 found AHWs reported that patients liked them smoking with them, facilitating connection and patients opening up.15 The same study reported that an organisational culture that supported smoking undermined quitting. However, we found that smoking was now usually not perceived as acceptable in ACCHSs.

Stress at work and at home has long been reported as the primary obstacle to successful quitting by AHWs.2,16 Research in other populations has shown that smoking for stress release is associated with relapse.17 However, successful quitting, for those who are able to do it, has been reported as being associated with reduced stress and, among Aboriginal people, with a general sense of pride and empowerment.18–20 Therefore, quitting smoking may reduce the stress these staff feel.

It does not appear, as previously reported, that a lack of quit support is a significant cause of relapse.2,16 Many quit attempts by staff received additional support from the health service, and use of stop-smoking medications was higher among staff than among other Aboriginal and Torres Strait Islander smokers. High smoking prevalence among the Aboriginal and Torres Strait Islander community has previously been suggested as a cause of failed quit attempts. We found high numbers of smokers among the close friends and family of both staff and community smokers, which has also been associated with relapse in other settings.17

Strengths and limitations

This is the largest national survey on smoking among ACCHS staff. However, as with our sample of community members, it is not a random sample, with both using similar non-probabilistic quota sampling designs, so caution in interpreting results is required. The staff and other community members in our sample are from the same geographically representative locations, and comparisons are directly standardised to the distribution of the population of smokers in the NATSISS. We have elsewhere shown that the 1643 smokers in our community sample were similar to smokers in the NATSISS, except for some inconsistent socioeconomic differences.9

We can compare our sample with 224 organisations providing primary health care services for Aboriginal and Torres Strait Islander people in 2011–12.21 These organisations included, but were not restricted to, member ACCHSs of the National Aboriginal Community Controlled Health Organisation, and included more services from remote areas (39%) and fewer from major cities (12%) than in our study.9 Similar proportions of staff were reported to be Aboriginal and Torres Strait Islander (57% of 5543 full-time equivalent staff) and to be doctors (6%) and nurses (14%) as in our sample (58%, 8% and 14%, respectively). Based on these criteria, there was limited response bias in our sample.

Unlike most similar previous research, we have chosen to report on all Aboriginal and Torres Strait Islander ACCHS staff, not just AHWs, as all these staff are health role models in their communities, and the distinction between AHWs and other roles at the ACCHS can vary across the country.

1 Comparison of smoking status of Aboriginal and Torres Strait Islander staff at ACCHSs with adults in the 2008 NATSISS

NATSISS participants*

ACCHS staff (n = 366)

Employed (n = 3772)

Total (n = 7163)

Status

Standardised % (frequency)†

% (95% CI)

Smoker

38% (146)

44.8% (42.1%–47.6%)

49.8% (47.8%–52.5%)

Ex-smoker

24% (88)

22.3% (20.2%–24.4%)

21.4% (19.8%–22.9%)

Never-smoker

38% (132)

32.9% (30.5%–35.5%)

28.8% (26.9%–30.7%)

ACCHS = Aboriginal community-controlled health service. NATSISS = National Aboriginal and Torres Strait Islander Social Survey. * NATSISS results only include those aged ≥ 18 years. † Staff survey percentages are directly standardised to the age, sex and remoteness distribution of smokers in the NATSISS.

2 Comparison of smoking and cessation practices of smokers among Aboriginal and Torres Strait Islander ACCHS staff and community members*

Practice	ACCHS staff, % (frequency)	Community members, % (frequency)	P

Smoking banned inside home			0.19
Total ban	64% (87)	56% (908)
Partial ban	22% (40)	22% (359)
No ban	14% (17)	22% (361)
Number of five closest family or friends who smoke			0.004
None	7% (14)	7% (120)
One	8% (14)	7% (119)
Two	10% (21)	15% (243)
Three	35% (31)	17% (273)
Four	12% (23)	12% (204)
Five	28% (43)	41% (649)
Noticed anti-smoking advertising in past 6 months			< 0.001
Often or very often	70% (116)	45% (730)
Sometimes	30% (28)	34% (535)
Never or almost never	1% (2)	21% (341)
Smokers who have ever made a quit attempt and have used NRT or stop-smoking medications	120	1155
Any NRT or medications	69% (71)	43% (505)	0.001
NRT patch	54% (48)	30% (362)	0.003
NRT gum	14% (21)	13% (152)	0.77
NRT lozenges	5% (6)	4% (42)	0.67
NRT tablets	5% (7)	2% (18)	0.03
Varenicline	49% (38)	13% (167)	< 0.001
Bupropion	9% (12)	1% (17)	< 0.001

ACCHS = Aboriginal community-controlled health service. NRT = nicotine replacement therapy. * Results for the baseline sample of Aboriginal and Torres Strait Islander ACCHS staff smokers (n = 146) and community smokers (n = 1643) in the Talking About The Smokes project, April 2012 – October 2013. Percentages and frequencies exclude those who did not answer or answered “don’t know”. Percentages are directly standardised to the age, sex and remoteness distribution of smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

3 Comparison of smoking and cessation attitudes of smokers among Aboriginal and Torres Strait Islander ACCHS staff and community members*

Attitude	ACCHS staff, % (frequency)	Community members, % (frequency)	P

How much do you think you would benefit from better health and other things if you were to quit smoking permanently in the next 6 months?			0.03
Very much or extremely	75% (113)	61% (988)
Moderately	20% (20)	21% (323)
Slightly or not at all	5% (6)	18% (293)
Smoking is not very risky when you think about all the other things that people do			0.19
Agree	30% (36)	46% (731)
Neither or don’t know	24% (32)	17% (282)
Disagree	46% (78)	37% (621)
Being a non-smoker sets a good example to children			0.52
Agree	87% (135)	91% (1482)
Neither or don’t know	4% (8)	4% (75)
Disagree	9% (3)	5% (77)
Cigarette smoke is dangerous to non-smokers			0.86
Agree	93% (131)	91% (1489)
Neither or don’t know	5% (13)	6% (99)
Disagree	2% (2)	3% (46)

ACCHS = Aboriginal community-controlled health service. * Results for the baseline sample of Aboriginal and Torres Strait Islander ACCHS staff smokers (n = 146) and community smokers (n = 1643) in the Talking About The Smokes project, April 2012 – October 2013. Percentages and frequencies exclude those who did not answer (all questions) or answered “don’t know” (first question). Percentages are directly standardised to the age, sex and remoteness distribution of smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

4 Confidence in talking with others about smoking and quitting among Aboriginal and Torres Strait Islander staff with client contact, by smoking status*

Confident in talking about smoking and quitting	Smokers (n = 103)	Ex-smokers (n = 65)	Never-smokers (n = 97)	Total (n = 265)

Very much or extremely	27% (28)	62% (40)	37% (36)	39% (104)
Moderately	25% (26)	26% (17)	30% (29)	27% (72)
Slightly or not at all	38% (39)	6% (4)	27% (26)	26% (69)
Don’t know	10% (10)	6% (4)	6% (6)	8% (20)

* Data are % (frequency) and exclude those not answering. χ2 test of association, P < 0.001.