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.

The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.

Statistical analyses

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.

General practitioner management of notifiable diseases is central to communicable disease control

To the Editor: Public health units routinely carry out investigations into cases of notifiable diseases, specified by state and territory Public Health Acts, because of the potential impact on the health of the public. Investigations involve contacting individuals and their contacts, and providing advice for follow up and treatment. This may include seeing a general practitioner for further testing, treatment, or prophylaxis of contacts.1 To assess the extent of input from GPs in managing notifiable diseases we documented GP encounters related to public health unit communicable disease control activity in inner-western and south-western Sydney.

Data on routine communicable disease activity in Sydney and Sydney South West Local Health Districts were collected over 2 months from 1 June to 31 July 2014. For all investigations into suspected and confirmed cases of notifiable disease, data were collected on the type of condition, visits to GPs and tests specifically requested as part of routine public health follow-up. The study was approved by Sydney Local Health District Ethics Review Committee. There were 220 investigations associated with suspected or confirmed cases of 34 notifiable conditions during the study period, requiring 212 GP visits and 286 tests. The Box lists conditions according to their required level of GP input (those involving GP encounters more than 50% of the time were considered to require high-level GP input). Influenza and gastroenteritis outbreaks, typhoid, rubella, hepatitis E and measles were the conditions requiring the highest level of GP input per investigation. Measles, arbovirus, pertussis and gastroenteritis outbreaks were conditions with the highest frequency of suspected or confirmed cases that also required high-level GP input. Based on population size, we estimated that, if extrapolated to state level, communicable disease control activities would have resulted in about 1047 GP visits across New South Wales in the same time period.

Our findings indicate that GP encounters are central to communicable disease control and shed light on which conditions require the most input from GPs. Influenza outbreaks, measles and gastroenteritis outbreaks are of particular concern. Influenza outbreaks require particularly high-intensity input from GPs, while measles and gastroenteritis outbreaks are frequently investigated conditions that require high-level GP input. Influenza and measles are serious conditions, often involving vulnerable populations (nursing home residents and children).2,3 Our results indicate that primary care plays an important role in protecting the public from conditions with potentially serious consequences. This finding should be considered in policy discussions about access to primary care.

Visits to general practitioners and tests associated with communicable disease investigations

Condition or infection investigated (suspected and confirmed cases)	No. of investigations	Average no. of visits per investigation	Average no. of tests per investigation

High-level GP input
Influenza outbreak*	5	14.8	20.2
Typhoid	1	9.0	17.0
Gastroenteritis outbreak†	17	2.1	3.7
Rubella	2	1.5	1.0
Hepatitis E	8	1.4	1.4
Measles	24	1.0	1.6
Varicella	1	1.0	1.0
Arbovirus	19	0.9	0.8
Pertussis	18	0.9	0.7
Legionella	9	0.8	0.9
Intermittent GP input
Hepatitis A	4	0.5	0.5
Q fever	2	0.5	1.0
MERS Co-V	2	0.5	1.0
Hepatitis B	7	0.4	0.4
Malaria	3	0.3	0.3
Shigella	11	0.2	0.3
< 16 Chlamydia‡	6	0.2	0.0
Salmonella	9	0.1	0.1
Cryptosporidiosis	11	0.1	0.0
No GP input
Rotavirus	5	0.0	0.0
Mumps	5	0.0	0.2
Meningococcal	7	0.0	0.0
Lymphogranuloma venereum	1	0.0	0.0
Invasive pneumoccocal disease	22	0.0	0.0
Hepatitis D	3	0.0	0.0
Hepatitis C	2	0.0	0.0
Haemophilis influenzae B	1	0.0	0.0
Diphtheria	4	0.0	0.5
Creutzfeldt–Jacob disease	1	0.0	0.0
Brucellosis	2	0.0	0.0
< 16 Gonorrhoea‡	1	0.0	0.0

MERS Co V = Middle East Respiratory syndrome (MERS) coronavirus. * Three or more epidemiologically linked cases of Influenza-like Illness in residents or staff of child care or aged care facilities within 72 hours PLUS at least one case with a positive laboratory test result OR at least two cases with a positive point-of-care test. † Two or more cases of vomiting or diarrhoea in an institution are followed up as a possible outbreak. ‡ Conditions followed up in children aged under 16 years only to ensure they are not at risk.

Use of nicotine replacement therapy and stop-smoking medicines in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers

In 2012–2013, 44% of Aboriginal and Torres Strait Islander adults smoked, 2.5 times the age-standardised prevalence among other Australian adults, and 26% were ex-smokers.1 Although the proportion of those who had ever smoked and had successfully quit was only 37%, compared with 63% of other Australians, this had increased from 24% in 2002.1,2 Several types of nicotine replacement therapy (NRT; gum, patches, lozenges, sublingual tablets and inhalers) and two prescription-only stop-smoking medicines (SSMs; bupropion and varenicline) are available in Australia to assist cessation.3 All have been shown to increase the chance of successfully quitting, with varenicline and combinations of NRT being the most effective.4

Nicotine gum became available in Australia in the 1980s, followed by patches in the 1990s and other forms of NRT in the past decade.3 Over-the-counter availability of NRT occurred first in pharmacies, then supermarkets. Subsidised availability by prescription for patches followed listing with the Pharmaceutical Benefits Scheme (PBS) for veterans from 1994, Aboriginal and Torres Strait Islander people from 2009, and all others from 2011. Bupropion was listed on the PBS in 2001, and varenicline in 2008.3 Since 1999, Aboriginal health services in remote areas have been able to dispense these PBS items at no cost through Section 100 of the National Health Act 1953.5 In addition, since July 2010, many non-remote Aboriginal health services and general practices participating in the Indigenous Health Incentive of the Practice Incentives Program have been able to reduce or eliminate the copayment for all PBS medicines, including SSMs, for their Aboriginal and Torres Strait Islander patients.6

Clinical guidelines suggest that NRT, bupropion or varenicline be recommended to all dependent smokers who are interested in quitting.7–9 Here, we explore the use of these medicines and beliefs about them among a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. We also explore variation in their use among dependent smokers in this population, and make comparisons with smokers in the general Australian population.

Methods

The Talking About The Smokes (TATS) project surveyed 1643 Aboriginal and Torres Strait Islander smokers and 78 recent ex-smokers (who had quit ≤ 12 months before), using a quota sampling design based on the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. It has been described in detail elsewhere.10,11 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or recent ex-smokers and 25 non-smokers, with equal numbers of women and men, and those aged 18–34 and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged under 18 years, not usual residents of the area, staff of the ACCHS or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. A single survey of health service activities was also completed at each site. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.10

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.12 We asked all smokers and recent ex-smokers whether they had ever used NRT or SSMs, and which they had used. For those who had used NRT, we asked if they were currently using it, when and for how long they last used it, where they got it and if it was free, and whether they would use it again in the future. We asked similar questions of those who had used SSMs. We asked all smokers and recent ex-smokers whether they thought NRT and SSMs help smokers to quit, and about their quit attempts and sociodemographic factors. The questions are described in detail in Appendix 1.

We used the Heaviness of Smoking Index (HSI) to assess dependence among daily smokers. The HSI was coded 0 to 6 based on the sum of the responses to two questions: cigarettes per day (CPD) and time to first cigarette (TTFC). These items were each coded as 0 (0–10 CPD; TTFC, ≥ 61 min), 1 (11–20 CPD; TTFC, 31–60 min), 2 (21–30 CPD; TTFC, 6–30 min) or 3 (≥ 31 CPD; TTFC, ≤ 5 min).13 We categorised HSI as low (0–1), moderate (2–3) or high (4–6).14,15 We also assessed the three criteria for dependence in the Royal Australian College of General Practitioners (RACGP) cessation guidelines: TTFC ≤ 30 min, > 10 CPD, and withdrawal symptoms on previous quit attempts (defined in our sample as strong cravings during the most recent quit attempt).7

TATS project results were compared with those of 1017 daily smokers surveyed in Wave 8 of the Australian ITC Project between July 2010 and May 2011. The ITC Project survey was completed by random digit telephone dialling or on the internet, and included smokers contacted for the first time and those who were recontacted after completing surveys in previous waves. For respondents who had completed surveys in previous waves, the ITC Project questions about use of NRT or SSMs were different to the TATS project questions, so for these comparisons we included only the 189 daily smokers who were newly recruited to the ITC Project.

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 the Australian ITC Project, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

Within the TATS project sample, we assessed the association between variables using logistic regression, with confidence intervals adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands).16 P values were calculated for each variable using adjusted Wald tests. However, we used χ2 tests to assess the association of variables with beliefs about whether NRT and SSMs help in quitting, and the association of past use with reasons for not intending to use them in the future. Median durations of NRT use are reported with interquartile ranges (IQRs) and were compared using the non-parametric equality of medians test.

Reported percentages and frequencies exclude those refusing to answer or answering “don’t know”, except for questions on future interest in NRT or SSM use and whether they help in quitting, which include those answering “don’t know”. Less than 2% of smokers and recent ex-smokers answered “don’t know” or refused to answer each of the questions analysed here.

Results

Compared with other daily Australian smokers in the ITC Project, lower proportions of Aboriginal and Torres Strait Islander daily smokers reported ever using any NRT or SSMs (37% [515/1379] v 58.5% [95% CI, 42.8%–72.6%]) and having used them in the past year (23% [318/1369] v 42.1% [95% CI, 29.4%–56.0%]).

Among all Aboriginal and Torres Strait Islander smokers and recent ex-smokers in the TATS project sample, 29% (501/1700) had ever used NRT and 11% (193/1700) had used SSMs. Nicotine patches were the most commonly used, by 24% (415/1699), followed by varenicline (11%; 183/1699), nicotine gum (10%; 174/1699), lozenges (3%; 50/1699), and inhalers (3%; 50/1699). Only 1% (17/1699) had used bupropion.

Of the Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had used NRT within the past year, most had last got it from an Aboriginal medical service (46%; 99/216), pharmacy (31%; 66/216) or another local health service (15%; 32/216), with only 3% (6/216) getting it from an ordinary store. Three-quarters (74%; 161/217) got their NRT at no cost, including almost all who got it from an Aboriginal medical service (93%; 92/99) or another local health service (91%; 29/32).

Of the Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had used NRT within the past year but were currently not using it, only 9% (16/174) had used it for the recommended period of more than 2 months;7–9 49% (85/174) used it for a week or less and 79% (138/174) for a month or less. The median duration of NRT use was 14 days (IQR, 3–30 days), with no significant differences by HSI score or whether it was free.

Aboriginal and Torres Strait Islander daily smokers who were more dependent, according to the HSI and RACGP criteria, were more likely to have ever used NRT or SSMs than those who were less dependent (Box 1). Fewer non-daily smokers than daily smokers or recent ex-smokers had ever used them. These associations were similar but less marked for use in the past year.

Among Aboriginal and Torres Strait Islander smokers who were at least moderately dependant (HSI score ≥ 2), the group for whom NRT and SSMs are recommended, those who were socioeconomically advantaged were more likely than the disadvantaged to have ever used NRT or SSMs and to have used them in the past year (Box 2). Use decreased with increasing remoteness and area-level disadvantage, increased with education, and was lower among those who reported being treated unfairly in the past year because they were Indigenous. Use also increased with age and was higher among smokers whose local health service had dedicated tobacco control resources. Those who were socioeconomically disadvantaged were even less likely to use SSMs than NRT (Appendix 2).

Most Aboriginal and Torres Strait Islander daily smokers said NRT and SSMs help smokers to quit: 70% said they help “very much” or “somewhat”, 16% said “not at all” and 14% did not know (Box 3). Similarly, the Australian ITC Project reported that 74.2% (95% CI, 68.9%–78.9%) of Australian daily smokers agreed that NRT and SSMs would make it easier to quit, 11.0% (95% CI, 8.7%–13.8%) disagreed, and 14.8% (95% CI, 10.8%–20.0%) neither agreed nor disagreed or did not know.

Having used NRT or SSMs was strongly associated with Aboriginal and Torres Strait Islander smokers believing that they help in quitting. Heavy smokers were more likely to believe that they would not help at all (Box 3).

Dependent Aboriginal and Torres Strait Islander smokers who believed NRT and SSMs would help in quitting and those who had used them (ever or in the past year) were more likely to be interested in using them in the future (Box 4). Frequency of strong urges to smoke and strong cravings on the most recent quit attempt were not associated with interest in future use of NRT and SSMs (data not shown).

The main reasons given by dependent smokers who were not interested in using NRT and SSMs in future were that they were not ready to quit (NRT, 36% [162/445]; SSMs, 29% [131/449]), because of side effects (19% [85/445]; 25% [114/449]), they did not think they would work (18% [81/445]; 16% [73/449]) and they preferred not to use them (16% [73/445]; 18% [82/449]). Cost was rarely mentioned as a reason (3% [15/445]; 2% [10/449]). There were significant differences between the reasons given by those who had and had not used NRT or SSMs in the past year (P < 0.001). Those who had used NRT were more likely than those who had not to say they would not use it in the future because of side effects (45% [26/58] v 15% [59/386]) and were less likely to report not being ready to quit (12% [7/58] v 40% [155/386]).

Discussion

We found lower use of NRT and SSMs among daily smokers in a large nationally representative Aboriginal and Torres Strait Islander sample than among those in the general Australian population. This is consistent with research in various countries that has found that smokers from more disadvantaged groups are less likely to use these medicines.17,18 We also found a social gradient of reducing use with increasing disadvantage (including perceived experiences of racism) within the Aboriginal and Torres Strait Islander community. Consistent with previous research, we found this gradient was steeper for the use of varenicline (bupropion accounted for very little of the SSM use) than for NRT.18,19

In recent years, many ACCHSs and their government funders have increased their focus on, and directed significant resources towards, tobacco control and cessation support. Our finding of greater use of SSMs by smokers whose local ACCHS had dedicated tobacco control resources provides some evidence for the effect of these policy decisions. We explore other non-pharmacological cessation support elsewhere in this supplement.20

Early research into Aboriginal and Torres Strait Islander smokers’ use of SSMs focused on the disincentive of the cost of NRT, and interventions to subsidise or provide free NRT.21–24 Covering the costs of treatment has been demonstrated to increase the use of NRT and bupropion in other contexts.25,26 Following policy changes, we found that nearly three-quarters of participants had got their most recent NRT at no cost, removing this financial impediment to its use. Unlike earlier research, cost was rarely given as a reason in our survey for not intending to use NRT or SSMs in the future.21,23 While some smokers are still paying a proportion of the cost, it is reassuring that policies to provide access to free NRT seem to be effectively reaching many Aboriginal and Torres Strait Islander smokers.

It is encouraging that a similar proportion of Aboriginal and Torres Strait Islander daily smokers as those in the broader Australian population think these medicines assist cessation. Further, Aboriginal and Torres Strait Islander smokers who were more dependent were more likely than the less dependent to have used them, in accordance with current clinical guidelines. However, there is still opportunity to improve their use. The clinical guidelines can be better promoted during the training and ongoing education of clinicians and tobacco control workers, to enable more frequent discussion about them with smokers. There remains a large proportion of Aboriginal and Torres Strait Islander smokers who have never used these medicines, are less likely to think they help and less likely to use them in the future, who could be informed about their effectiveness in assisting quitting.27

The frequent use of NRT for much less than the recommended 8 weeks is similar to earlier reports in this population; likewise, the median duration was similar to those found in other research in Australia and elsewhere, particularly the shorter durations reported when NRT is available over the counter rather than by prescription.22,28–31 Research into the common reasons for stopping NRT and SSMs (resuming smoking, side effects and the belief that it has already worked) suggests that these are generally legitimate and may not be cause for great concern. For example, data from other ITC Project surveys show that 66% of those who stopped early because they believed that they no longer needed the medication were still abstinent at 6 months.30

There has been a significant increase in the use of SSMs in Australia in recent years, especially associated with the release of varenicline in 2008.32 The release of new varieties of NRT and other SSMs has also been shown to be associated with this increase in the total use of SSMs, often with very little compensatory decline in the use of older medicines.19,26,32 We found that a variety of types of NRT were used (most commonly patches), as well as varenicline and a small amount of bupropion. The range of NRT formulations and other medicines is likely to increase in the future.3 The potential impact of e-cigarettes as an aid to cessation remains unclear and contested.33,34

Strengths and limitations

The main strength of our study is its large national sample of Aboriginal and Torres Strait Islander smokers, providing the first detailed national information about the use of NRT and SSMs in this population. However, it is a non-random, albeit broadly representative, sample, and caution is needed in interpreting the comparisons with the Australian ITC Project sample and in generalising the results to the whole Aboriginal and Torres Strait Islander population. The use of NRT or SSMs in our sample of Aboriginal and Torres Strait Islander people in communities served by ACCHSs may be different to that in communities without access to an ACCHS, who use private general practices. Our self-reported data are probably limited by incomplete recall of past use of NRT and SSMs and quit attempts. The effect of these biases will be to weaken reported associations, leading to greater confidence in the significant associations but requiring caution in the implications of findings of no association.

1 Aboriginal and Torres Strait Islander use of nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs)

Ever used NRT or SSMs

Used NRT or SSMs in the past year

Smoking characteristic

% (frequency)*

Odds ratio (95% CI)†

P‡

% (frequency)*

Odds ratio (95% CI)†

P‡

Smokers and recent ex-smokers (n = 1721)

Smoking status

Daily smokers

37% (515)

1.0

< 0.001

23% (318)

1.0

0.001

Non-daily smokers

17% (43)

0.35 (0.24–0.51)

12% (30)

0.46 (0.29–0.73)

Recent ex-smokers§

36% (28)

0.94 (0.57–1.55)

32% (25)

1.59 (0.95–2.66)

Daily smokers only (n = 1369)

Heaviness of Smoking Index score

Low (0–1)

30% (69)

1.0

< 0.001

18% (42)

1.0

0.06

Moderate (2–3)

36% (284)

1.34 (1.00–1.81)

23% (184)

1.39 (0.92–2.08)

Heavy (4–6)

45% (148)

1.98 (1.42–2.76)

27% (86)

1.65 (1.08–2.51)

RACGP criteria for dependence¶

None

24% (38)

1.0

< 0.001

13% (20)

1.0

< 0.001

One

27% (91)

1.23 (0.78–1.92)

17% (55)

1.38 (0.84–2.28)

Two

35% (192)

1.71 (1.12–2.61)

21% (118)

1.89 (1.11–3.22)

All three

59% (193)

4.66 (2.99–7.27)

39% (125)

4.39 (2.56–7.51)

RACGP = Royal Australian College of General Practitioners. * Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values for the entire variable, using adjusted Wald tests. § Those who had quit ≤ 12 months before. ¶ Time to first cigarette ≤ 30 min, > 10 cigarettes per day, and withdrawal symptoms on previous quit attempts (strong cravings during most recent quit attempt).

2 Use of nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs) by dependent Aboriginal and Torres Strait Islander smokers,* by sociodemographic factors (n = 1124)

	Ever used NRT or SSMs			Used NRT or SSMs in the past year
Sociodemographic factor	% (frequency)†	Odds ratio (95% CI)‡	P§	% (frequency)†	Odds ratio (95% CI)‡	P§

All dependent smokers	39% (432)			24% (270)
Age (years)			0.002			0.08
18–24	28% (59)	1.0		18% (39)	1.0
25–34	35% (102)	1.43 (0.98–2.08)		23% (67)	1.35 (0.91–2.02)
35–44	40% (112)	1.78 (1.12–2.83)		24% (65)	1.37 (0.85–2.23)
45–54	44% (86)	2.07 (1.29–3.33)		29% (55)	1.78 (1.12–2.83)
≥ 55	53% (73)	3.00 (1.79–5.01)		32% (44)	2.13 (1.25–3.64)
Sex			0.18			0.11
Female	41% (233)	1.0		27% (150)	1.0
Male	36% (199)	0.80 (0.58–1.11)		22% (120)	0.77 (0.55–1.07)
Indigenous status			0.14			0.76
Aboriginal	40% (398)	1.0		25% (245)	1.0
Torres Strait Islander or both	31% (34)	0.70 (0.44–1.12)		23% (25)	0.93 (0.56–1.52)
Labour force status			< 0.001			0.02
Employed	45% (166)	1.0		29% (105)	1.0
Unemployed	30% (113)	0.51 (0.38–0.70)		20% (76)	0.62 (0.45–0.86)
Not in labour force	41% (151)	0.85 (0.64–1.14)		24% (88)	0.80 (0.56–1.14)
Highest education attained			0.001			0.03
Less than Year 12	35% (206)	1.0		21% (127)	1.0
Finished Year 12	38% (109)	1.18 (0.88–1.58)		26% (73)	1.28 (0.92–1.78)
Post-school qualification	50% (115)	1.90 (1.36–2.67)		30% (68)	1.58 (1.12–2.23)
Treated unfairly because Indigenous in past year			0.01			0.02
No	43% (207)	1.0		28% (135)	1.0
Yes	35% (214)	0.71 (0.54–0.92)		21% (129)	0.68 (0.50–0.93)
Remoteness			0.002			0.03
Major cities	43% (127)	1.0		29% (85)	1.0
Inner and outer regional	41% (239)	0.94 (0.60–1.47)		25% (141)	0.80 (0.53–1.20)
Remote and very remote	27% (66)	0.50 (0.31–0.80)		18% (44)	0.54 (0.34–0.86)
Area-level disadvantage			0.03			0.02
1st quintile (most disadvantaged)	33% (141)	1.0		19% (81)	1.0
2nd and 3rd quintiles	41% (189)	1.40 (1.01–1.94)		27% (122)	1.54 (1.09–2.17)
4th and 5th quintiles	45% (102)	1.64 (1.07–2.51)		30% (67)	1.78 (1.10–2.87)
Local health service has dedicated tobacco control resources			0.006			0.003
No	31% (97)	1.0		18% (57)	1.0
Yes	42% (335)	1.66 (1.16–2.37)		27% (213)	1.70 (1.20–2.39)

* Daily smokers with Heaviness of Smoking Index scores ≥ 2. † Percentages and frequencies exclude those answering “don’t know” or refusing to answer. ‡ Odds ratios calculated using simple logistic regression adjusted for the sampling design. § P values for the entire variable, using adjusted Wald tests.

3 Aboriginal and Torres Strait Islander smokers and recent ex-smokers’ beliefs about whether nicotine replacement therapy (NRT) and stop-smoking medicines (SSMs) help smokers to quit*

	Do you think NRT and SSMs help smokers to quit?
Smoker characteristics	Very much	Somewhat	Not at all	Don’t know or haven’t heard of them	P†

Smokers and recent ex-smokers (n = 1721)	20% (337)	51% (867)	16% (274)	14% (234)‡
Ever used NRT or SSMs					< 0.001
Yes	31% (179)	55% (324)	9% (50)	5% (32)
No	14% (158)	48% (541)	20% (223)	18% (196)
Used NRT or SSMs in the past year					< 0.001
Yes	35% (132)	53% (197)	7% (27)	5% (17)
No	15% (203)	50% (659)	19% (245)	16% (211)
Smoking status					0.2
Daily smokers	19% (268)	51% (700)	16% (218)	14% (197)
Non-daily smokers	18% (45)	53% (132)	18% (44)	12% (30)
Recent ex-smokers§	31% (24)	45% (35)	15% (12)	9% (7)
Daily smokers only (n = 1383)
Heaviness of Smoking Index score					0.007
Low (0–1)	17% (39)	49% (115)	14% (33)	20% (46)
Moderate (2–3)	20% (161)	53% (416)	14% (112)	13% (103)
Heavy (4–6)	19% (61)	46% (149)	22% (70)	14% (45)

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer, except for whether NRT and SSMs help, which do include those answering “don’t know”. † P values were calculated using the χ2 test adjusted for sampling design. ‡ Comprises 19 smokers and recent ex-smokers who had not heard of NRT and SSMs, and 215 who did not know if they helped smokers to quit. § Those who had quit ≤ 12 months before.

4 Interest in using nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs) to help quit smoking in the future among dependent Aboriginal and Torres Strait Islander smokers* (n = 1124)

	Interested in using NRT in the future					Interested in using SSMs in the future
	% (frequency)†			Odds ratio (95% CI)‡	P§	% (frequency)†			Odds ratio (95% CI)‡	P§
Variable	Yes	No	Don’t know	Odds ratio (95% CI)‡	P§	Yes	No	Don’t know	Odds ratio (95% CI)‡	P§

All dependent smokers	54% (608)	41% (462)	4% (47)			51% (575)	42% (470)	7% (73)
Think NRT and SSMs help smokers to quit					< 0.001					< 0.001
Not at all	24% (43)	73% (132)	4% (7)	1.0		23% (42)	74% (134)	3% (6)	1.0
Somewhat	59% (335)	37% (211)	3% (19)	4.87 (3.19–7.45)		58% (325)	37% (209)	5% (31)	4.96 (3.18–7.73)
Very much	80% (177)	18% (40)	2% (4)	13.58 (8.29–22.26)		74% (164)	23% (51)	3% (7)	10.26 (6.3–16.7)
Don’t know or haven’t heard of them	36% (53)	53% (78)	11% (17)			30% (44)	51% (75)	20% (29)
Ever used NRT or SSMs					< 0.001					< 0.001
No	48% (352)	48% (354)	5% (34)	1.0		48% (461)	46% (438)	6% (62)	1.0
Yes	69% (255)	29% (106)	2% (8)	2.42 (1.82–3.22)		75% (112)	21% (31)	4% (6)	3.43 (2.22–5.31)
Used NRT or SSMs in the past year					< 0.001					< 0.001
No	49% (427)	46% (401)	5% (41)	1.0		49% (499)	45% (454)	6% (65)	1.0
Yes	74% (176)	25% (60)	1% (2)	2.75 (1.95–3.90)		78% (72)	17% (16)	4% (4)	4.09 (2.21–7.57)
Heaviness of Smoking Index score					0.05					< 0.001
Moderate (2–3)	56% (446)	39% (311)	4% (34)	1.0		53% (418)	41% (323)	6% (51)	1.0
Heavy (4–6)	50% (162)	46% (151)	4% (13)	0.75 (0.56–0.99)		48% (157)	45% (147)	7% (22)	0.83 (0.62–1.09)

* Daily smokers with Heaviness of Smoking Index scores ≥ 2. † Percentages and frequencies exclude those answering “don’t know” or refusing to answer, except for questions on future interest in NRT or SSM use and whether they help in quitting, which include those answering “don’t know”. ‡ Odds ratios calculated using simple logistic regression adjusted for the sampling design. § P values for the entire variable, using adjusted Wald tests.

Inappropriate pathology ordering and pathology stewardship

To the Editor: We commend Spelman’s insightful discussion of the need for pathology stewardship.1

The Royal College of Pathologists of Australasia (RCPA) advocates a structured approach underpinned by national standards, aimed at minimising harm to patients as well as reducing laboratory and hospital costs. The College recommends hospital pathology stewardship programs with multidisciplinary input; harmonisation of testing and reporting; electronic decision support systems; educational strategies; and collection and analysis of national and state data.

Within this advocacy framework, the RCPA has led or collaborated on many projects relating to harmonisation, standardisation and structuring of reports, consumer benefits and risks, effective communication of results, point-of-care testing, quality of genetic testing (http://www.health.gov.au/internet/main/publishing.nsf/Content/pathology-qupp-index), and a free online educational tool for doctors (http://investigate.med.unsw.edu.au/home.jsf). The College advocates and advises on pathology rotations for junior doctors.

The RCPA Manual (http://www.rcpa.edu.au/Library/Practising-Pathology/RCPA-Manual/Home) provides decision support tools and comprehensive guidance on use and interpretation of pathology investigations.

While these initiatives will promote quality use of pathology, we stress that coordinated support from major national institutions is needed to effect real change.

Smoking cessation advice and non-pharmacological support in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers

Quitting smoking reduces the risk of smoking-related death, with greater benefits from quitting at a younger age.1 Receiving brief advice to quit from health professionals and more intensive support from specialist clinics and courses, stop-smoking medicines, telephone quitlines, websites and printed materials have been shown to increase successful quitting.2–8 In Australia, just over half of smokers have been recently advised to quit, and a similar proportion of those who have tried to quit have used stop-smoking medicines.9,10 Fewer smokers are referred to or use other cessation support services.9–11

In 2012–2013, Aboriginal and Torres Strait Islander adults had 2.5 times the smoking prevalence of other Australian adults, and those who had ever smoked were less likely to have successfully quit (37% v 63%).12 There is a long history of widespread training in how to give brief advice for health professionals working with Aboriginal and Torres Strait Islander peoples.13 In recent years, the national Tackling Indigenous Smoking program has increased funding to support this training, enhancement of the telephone Quitline service to be more culturally appropriate, and other local cessation support activities.14

Here, we describe recall among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers of having received advice to quit smoking and referral to non-pharmacological cessation support from health professionals, and examine the association of advice and referrals with making a quit attempt. We examine the use of stop-smoking medicines elsewhere in this supplement.15

Methods

The Talking About The Smokes (TATS) project surveyed 1643 Aboriginal and Torres Strait Islander smokers and 78 recent ex-smokers (who had quit ≤ 12 months before), using a quota sampling design based on the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. It has been described in detail elsewhere.16,17 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or recent ex-smokers and 25 non-smokers, with equal numbers of women and men, and those aged 18–34 and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged under 18 years, not usual residents of the area, staff of the ACCHS or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

We asked all smokers and recent ex-smokers whether they had seen a health professional in the past year and, if so, whether they had been asked if they smoke and, if so, whether they had been encouraged to quit. We asked those who had been encouraged to quit about pamphlets or referrals to the Quitline, quit-smoking websites, or quit courses or clinics they had received. We also asked all smokers and recent ex-smokers whether they had sought out these services themselves, and about quit attempts and sociodemographic factors. At each site, we asked questions about tobacco control funding and staff positions to determine if the health service had resources dedicated to tobacco control. The questions reported here are described in detail in Appendix 1.

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.18 TATS project results were compared with those of 1412 daily smokers newly recruited to Waves 5–8 (2006–2011) of the Australian ITC Project. The ITC Project survey was conducted by random digit telephone dialling. We only used data from the newly recruited participants as questions for recontacted participants referred to advice received since the previous survey rather than in the past year. Slightly different definitions of smokers between the TATS project and ITC Project surveys meant that only daily and weekly smoker categories were directly comparable. We concentrated our comparisons on daily smokers. We have also concentrated our other descriptions of recall of advice and associations between variables within the TATS sample on daily smokers.

Statistical analyses

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

Within the TATS project sample, we assessed the association between variables using simple logistic regression, with confidence intervals adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands.19 P values were calculated using adjusted Wald tests.

Reported percentages and frequencies exclude those refusing to answer or answering “don’t know”, leading to minor variations in denominators between questions. Less than 2% of daily smokers answered “don’t know” or refused to answer each of the questions analysed here.

Results

Three-quarters of Aboriginal and Torres Strait Islander daily smokers (76%) reported having seen a health professional in the past year (Box 1). Of these, 93% said they were asked if they smoked, and 75% also reported being advised to quit. These proportions are higher than those among Australian daily smokers in the ITC Project.

Within the TATS project sample, Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional had twice the odds of having made a quit attempt in the past year, compared with those who did not recall being advised to quit (Box 2).

The proportion of Aboriginal and Torres Strait Islander daily smokers who had been advised to quit increased with age and was higher among women, those with post-school qualifications and those whose local health service had dedicated tobacco control resources; the proportion was lower among the unemployed (Box 3). There was more sociodemographic variation in having seen a health professional than in recalling being advised to quit (Appendix 2).

Among all Aboriginal and Torres Strait Islander smokers and ex-smokers who were advised to quit, 49% were given a pamphlet or brochure on how to quit, and lower proportions were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%) (Box 4). Most of those who received pamphlets said they read them (70%, 321/457), but lower proportions reported following up on other referrals. Daily smokers who were referred to each resource were non-significantly more likely to have made a quit attempt in the past year than those who had been advised to quit but not referred (Box 2). We also found that 13% of smokers and recent ex-smokers (215/1696) had sought out quit information or services themselves, and that 62% (1047/1692) had been encouraged by family or friends to quit or to maintain a quit attempt.

A higher proportion of the Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional in the past year had been given a pamphlet, compared with other Australian daily smokers in the ITC Project (50% [390/778] v 29.6% [95% CI, 25.4%–34.3%]).

Discussion

Daily smokers in our Aboriginal and Torres Strait Islander sample were more likely than those in the broader Australian ITC Project sample to recall having been advised to quit by a health professional in the past year. This was in part due to being more likely to have been seen by a health professional, but mainly due to a greater proportion of those seen being advised to quit.

Strengths and limitations

The main strength of this study is its large, nationally representative sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. However, the sample was not random and there were some sociodemographic differences compared with a random sample of the population.16

Our survey was conducted face to face, whereas the comparison Australian ITC Project surveys were conducted by telephone, potentially leading to differential social desirability bias. Further, some ITC Project surveys were conducted much earlier than the TATS project survey, and although many questions were identical on both surveys, the order and structure of the comparison ITC Project questionnaire was different. While we are confident that the large difference in recall of health professional advice between the TATS project and ITC Project samples is real, we have not described the differences in referral to cessation support as, except for the question about pamphlets, the questions were not directly comparable.

The main limitation of our study is that partnering with ACCHSs to recruit participants may have led to a selection bias towards people with closer connections to the health services, inflating the percentage who recalled being seen by a health professional. However, this percentage was similar to that reported in the 2004–2005 National Aboriginal and Torres Strait Islander Health Survey.16 We also report a higher prevalence of having received advice among only those who had seen a health professional, which would be less affected by this bias. Our results are also based on patient recall, not clinical records. Australian general practice research has found that clinical records poorly record health advice and poorly agree with patient recall of referrals to other cessation services.10 Some patients will have misremembered or forgotten advice and referrals they received, but we would expect that advice and referrals that were useful for quitting would be more likely to be remembered.

Comparisons with other studies

The proportion of smokers who had seen a health professional and recalled being asked if they smoke was similar to that among a sample of pregnant Aboriginal and Torres Strait Islander women who smoked, who were only slightly more likely to be advised to quit (81% of pregnant smokers v 75% of daily smokers in our sample).20

SmokeCheck, a commonly used training program to increase health professionals’ skills in giving brief quit-smoking advice to Aboriginal and Torres Strait Islander patients, has been shown to improve participants’ confidence in regularly providing brief advice.21,22 The long history of such training programs, along with support for and promotion of brief interventions in ACCHSs, may have contributed to advice being given more often to Aboriginal and Torres Strait Islander smokers than other smokers.

We found that the likelihood of receiving advice to quit from health professionals increased with participant age, as in earlier Australian ITC Project research.9 Most of the focus of chronic disease prevention is on older patients, but there is an opportunity to increase the provision of advice about smoking to younger patients.

Our finding that a high proportion of Aboriginal and Torres Strait Islander daily smokers recalled receiving this advice is encouraging, as even brief advice from a doctor increases cessation, with minimal additional benefit from more extensive advice or follow-up.2 Provision of brief advice is achievable even in very busy primary care settings and, as we found, can reach most of the population. In both urban and remote settings, Aboriginal and Torres Strait Islander interviewees in qualitative research have emphasised that advice and support from health professionals was a significant factor in their quit attempts.23–25 Consistent with this, we found that recalling advice from a health professional to quit was associated with making a quit attempt. While it is possible that making an attempt may increase the likelihood of advice being recalled, or may have led to making a visit to a health professional, it seems reasonable to conclude that advice from health professionals is contributing to Aboriginal and Torres Strait Islander smokers’ motivation to try to quit.

The frequent use of pamphlets by Aboriginal and Torres Strait Islander smokers is positive but not likely to have much impact on cessation, as the additional effect of such printed material is only modest.6 In contrast, Cochrane reviews show a greater effect on cessation of telephone quitlines, more intensive individual counselling outside primary care, and quit groups.4,7,8 Currently, evidence for internet-based quit support is inconsistent but promising.5

A meta-analysis of two randomised controlled trials showed intensive cessation counselling programs for Aboriginal and Torres Strait Islander smokers were effective in increasing cessation.26 We found that most people who attended special cessation programs said they were specifically designed for Aboriginal and Torres Strait Islander peoples.

Quitlines can be a cost-effective element in cessation support, but there has been a perception of distrust and low usage of quitlines by Aboriginal and Torres Strait Islander people.13 In 2010, Aboriginal and Torres Strait Islander callers to the Quitline in South Australia received fewer calls back and were less likely to have successfully quit than non-Indigenous callers.27 Since then, the Tackling Indigenous Smoking program has funded activity to improve the appropriateness and accessibility of the Quitline.

These non-pharmacological cessation support options benefit smokers who use them, but we found that most do not, as has been found in other contexts.9–11 Indigenous and non-Indigenous Australian research has shown that many smokers see using cessation support as a sign of weakness and lack of willpower, which is a challenge in promoting these evidence-based services.24,28

1 Daily smokers’ recall of receiving advice to quit when seeing a health professional in the past year*

Australian ITC Project, % (95% CI)†

TATS project, % (frequency)‡

Seen a health professional

68.1% (64.8%–71.1%)

76% (1047)

Of those seen

Asked if he/she smokes§

—

93% (968)

Advised to quit

56.2% (52.3%–59.9%)

75% (782)

ITC Project = International Tobacco Control Policy Evaluation Project. TATS = Talking About The Smokes. * Percentages and frequencies exclude refused responses and “don’t know” responses. † Results are for daily smokers (n = 1412) newly recruited to Waves 5–8 of the Australian ITC Project (2006–2011) and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results are for Aboriginal and Torres Strait Islander daily smokers (n = 1377) in the baseline sample of the TATS project (April 2012 – October 2013). § Not asked in the Australian ITC Project.

2 Aboriginal and Torres Strait Islander daily smokers who made a quit attempt in the past year, by recall of being advised to quit and referred to cessation support

	Attempted to quit in the past year
	% (frequency)*	Odds ratio (95% CI)†	P‡

All daily smokers (n = 1354)
Advised to quit by a health professional in the past year			< 0.001
No	39% (223)	1.0
Yes	56% (433)	2.00 (1.58–2.52)
If advised to quit by a health professional in the past year (n = 777)§
Given a pamphlet			0.053
No	52% (203)	1.0
Yes	60% (230)	1.34 (1.00–1.79)
Referred to telephone Quitline			0.15
No	55% (306)	1.0
Yes	60% (125)	1.25 (0.92–1.68)
Referred to quit-smoking website			0.48
No	55% (305)	1.0
Yes	58% (121)	1.13 (0.80–1.6)
Referred to quit course, group or clinic			0.19
No	55% (357)	1.0
Yes	61% (73)	1.30 (0.88–1.92)

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated using adjusted Wald tests. § Only participants who recalled being advised to quit by a health professional were asked about referral to cessation support resources.

3 Aboriginal and Torres Strait Islander daily smokers who recalled being advised to quit by a health professional in the past year, by sociodemographic factors (n = 1366)

	Advised to quit by a health professional
Characteristic	% (frequency)*	Odds ratio (95% CI)†	P‡

Total	57% (782)
Age (years)			0.001
18–24	48% (136)	1.0
25–34	55% (203)	1.29 (0.93–1.79)
35–44	58% (188)	1.47 (1.01–2.16)
45–54	62% (145)	1.72 (1.15–2.57)
≥ 55	71% (110)	2.61 (1.67–4.06)
Sex			0.003
Male	52% (342)	1.0
Female	62% (440)	1.50 (1.15–1.95)
Indigenous status			0.74
Aboriginal	57% (694)	1.0
Torres Strait Islander or both	59% (88)	1.07 (0.73–1.56)
Labour force status			< 0.001
Unemployed	48% (226)	1.0
Not in labour force	65% (273)	2.00 (1.47–2.71)
Employed	59% (282)	1.57 (1.20–2.05)
Highest education attained			0.007
Less than Year 12	54% (380)	1.0
Finished Year 12	57% (206)	1.17 (0.91–1.51)
Post-school qualification	66% (194)	1.72 (1.23–2.41)
Treated unfairly because Indigenous in past year			0.72
No	58% (342)	1.0
Yes	57% (423)	0.96 (0.75–1.22)
Remoteness			0.33
Major cities	54% (194)	1.0
Inner and outer regional	60% (430)	1.25 (0.86–1.81)
Remote and very remote	54% (158)	0.98 (0.64–1.52)
Area-level disadvantage			0.18
1st quintile (most disadvantaged)	55% (285)	1.0
2nd and 3rd quintiles	61% (357)	1.28 (0.94–1.74)
4th and 5th quintiles	54% (140)	0.97 (0.68–1.38)
Local health service has dedicated tobacco control resources			0.05
No	52% (207)	1.0
Yes	60% (575)	1.38 (1.00–1.91)

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated for the entire variable, using adjusted Wald tests.

4 Aboriginal and Torres Strait Islander smokers and recent ex-smokers who recalled receiving or being referred to cessation support resources when advised to quit by a health professional (n = 960)*

	Pamphlet	Quit-smoking website	Telephone Quitline	Quit course, group or clinic

Received information or a referral	49% (460)	27% (252)	28% (266)	16% (149)
If so, read, used or attended it	70% (321)	22% (54)	16% (43)	44% (65)
If so, it was specifically for Aboriginal and Torres Strait Islander peoples	52% (168)	48% (26)	44% (18)	88% (56)

* Data only include smokers and recent ex-smokers who recalled being advised by a health professional to quit. Percentages and frequencies exclude those answering “don’t know” or refusing to answer.

Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers

Television advertisements and warning labels on tobacco products are the most commonly cited sources of information on the dangers of smoking.1,2 There is good evidence that messages about the harms of smoking increase knowledge, worry about health risks, attempts to quit, and even quit success.3–7 These messages aim to either change pro-smoking attitudes and intentions or strengthen those that support quitting.8

Smoking is the leading cause of sickness and death among Aboriginal and Torres Strait Islander peoples.9 To tackle this, funding was established in 2009 for community-led programs that raise awareness, provide education and challenge norms about smoking.10 Australia also launched its first national Indigenous Anti-Smoking Campaign (“Break the Chain”) in March 2011.11 These targeted programs ran alongside the National Tobacco Campaign, state and territory campaigns, and other sources of information, such as news media. In addition, plain packaging of tobacco products, with new and larger warning labels, was mandated from 1 December 2012.12

Some experts doubt the effectiveness of mainstream messages in reducing smoking among Aboriginal and Torres Strait Islander peoples.13 While culturally relevant messages are preferred,14 mainstream media campaigns achieve high recall,15–17 including in remote areas.17,18 Here, we describe recall of anti-tobacco advertising and information (mainstream and targeted), pack warning labels and news stories among Aboriginal and Torres Strait Islander smokers, and assess the association of these messages with attitudes that support quitting.

Methods

Survey design and participants

The Talking About The Smokes (TATS) project surveyed 1643 current smokers from April 2012 to October 2013 (Wave 1, or baseline), and has been described in detail elsewhere.19,20 Briefly, we used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait (project sites), which were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers or recent quitters (ex-smokers who had quit ≤ 12 months previously), with even numbers of men and women, and people aged 18–34 and ≥ 35 years. The sample size was doubled in four large city sites and in the Torres Strait community. People were excluded if they did not identify as Aboriginal or Torres Strait Islander, were under 18 years of age, were not usual residents of the area, were staff of the ACCHS, were unable to complete the survey in English if there was no interpreter available, or if the quota for the relevant age–sex–smoking category had been filled. In each site, different locally determined methods were used to collect a representative, albeit non-random, sample.

The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and by number of cigarettes smoked per day for current daily smokers. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.19

Questions on health information exposure

As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), survey questions were based on ITC Project survey questions and are presented in Appendix 1. How often respondents noticed warning labels (in the past month), anti-tobacco news stories (in the past 6 months) and anti-tobacco advertising or information (in the past 6 months) was assessed on a five-point scale ranging from “never” to “very often”, which was later collapsed to three categories (never, sometimes, often).

Smokers who said they had never noticed advertising or information (hereafter collectively referred to as advertising) in the past 6 months were not asked further related questions. Smokers who had noticed advertising were asked whether it was on: television, radio, the internet, outdoor billboards, newspapers or magazines, shops or stores, pamphlets, and posters in various locations (yes or no). Those who recalled noticing advertising in the past 6 months were also asked whether any had featured an Aboriginal or Torres Strait Islander person or artwork (“targeted advertising”) and, if so, whether any featured an Aboriginal or Torres Strait Islander person or artwork from the local community (“local advertising”). We combined these responses to create the variable “type of advertising”, which categorised smokers as having: never noticed any advertising, noticed mainstream (but no targeted) advertising, noticed some targeted (but no local) advertising, or noticed some local advertising.

Main outcome measures and covariates

There were four main outcomes: believing smoking is dangerous to others (“agree” or “strongly agree” that cigarette smoke is dangerous to both non-smokers and children), being very worried that smoking will damage the smoker’s own health in the future, agreeing that mainstream society disapproves of smoking, and wanting to quit. Additional analyses were conducted on forgoing cigarettes because of warning labels.

Covariates included daily or non-daily smoking status and key sociodemographic indicators (sex, age, identification as Aboriginal and/or Torres Strait Islander, labour force status, education, remoteness and area-level disadvantage). We also assessed for variation according to tobacco control activity that had occurred at the project site over the previous year (whether there were dedicated tobacco control resources, and the number of media used to communicate anti-tobacco advertising), which was determined in the project site survey.

We also assessed differences in warning label recall before and after plain packaging was mandated (1 December 2012), treating the 3-month phase-in period as “before”.

Statistical analyses

Logistic regression was used to assess: (i) variation in health information recall (often v sometimes or never) by daily smoking status, sociodemographic variables, and tobacco control activity at the project site; (ii) the association between health information recall and the four main outcome measures; and (iii) variation in warning label recall and outcomes before and after plain packaging was mandated. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, identifying the 35 project sites as clusters and the quotas (based on age, sex and smoking status) as strata.21

Data for health information recall were excluded for less than 2% of participants due to missing or refused responses, and for less than 2% due to “don’t know” responses. Questions about recall of warning labels were not asked of those who had not smoked in the past month (n = 44), nor those surveyed at the first project site (n = 26), after which questions were modified. These participants were therefore excluded from logistic regression analyses, which controlled for recall of each other type of health information, survey month (collapsed into 2-month blocks), daily smoking status and other sociodemographic covariates. Regression analyses for wanting to quit excluded a further 4.8% of smokers who responded “don’t know” to this question.

Results

Recall of health information

Of smokers who were asked about warning labels, 65% (1015/1557) said they had often noticed warning labels in the past month (Box 1). This was higher than the proportion of all smokers who recalled often noticing anti-tobacco advertising (45%; 730/1606) or news stories (24%; 386/1601) in the past 6 months.

Frequent recall of health information was similar for daily and non-daily smokers (Appendix 2). Fewer men than women reported often noticing warning labels (odds ratio [OR], 0.68; 95% CI, 0.51–0.90) and news stories (OR, 0.71; 95% CI, 0.51–1.00). While smokers from remote areas were less likely than those in major cities to recall often noticing advertising (OR, 0.56; 95% CI, 0.37–0.84), they were more likely to recall often noticing news stories (OR, 1.81; 95% CI, 1.18–2.79) and did not differ for recall of warning labels. Being from an area where the health service used a greater range of advertising media was associated with noticing it more often, with ORs increasing from 2.02 (95% CI, 1.15–3.57) for 5–8 media to 3.17 (95% CI, 1.84–5.46) for 9–12 media, compared with areas that used four or fewer media.

Associations with attitudes and wanting to quit

Recall of warning labels, advertising and news stories was positively associated with being very worried about future health and wanting to quit (Box 2). Only advertising recall was positively associated with believing society disapproves of smoking. For each outcome, the magnitude of ORs increased for those who recalled more targeted and local advertising, although this association was only significant for believing cigarette smoke is dangerous to others and wanting to quit.

Outcomes for warning labels before and after plain packaging

Compared with smokers surveyed in the period before plain packaging, those surveyed after its introduction were similarly likely to recall noticing warning labels but had higher odds for believing the labels made them more likely to quit (OR, 1.37; 95% CI 1.02–1.82) (Appendix 3). Smokers who had noticed warning labels in the past month were more likely to say these labels led them to forgo at least one cigarette after plain packaging compared with before it (OR, 1.54; 95% CI, 1.14–2.09). Further, those who said warning labels led them to forgo at least one cigarette were more likely to want to quit (OR, 3.73; 95% CI, 2.63–5.29) (data not shown).

Discussion

Advertising and information

We found high levels of recall of anti-tobacco advertising and information, particularly for television campaigns and local health promotion materials, which is likely to have been boosted by the community-led tobacco control activity that occurred over the survey period. However, even with this heightened activity, smokers from remote areas were less likely to say they often noticed advertising, consistent with trends for national mass media exposure.22 Recall of mass media advertising has been shown to increase with broadcast intensity,23–25 which is fundamental to achieving good reach among smokers of low socioeconomic status.6,25–27 Broadcast intensity is also important for influencing quitting activity and success.5,6,22,25,28,29

It is notable that targeted and local advertising was associated with higher levels of motivation to quit, a novel finding as far as we are aware. In part, targeted campaigns may be more memorable purely because of the interest in their targeted or local nature,30 which could be expected to weaken the observed relationship with wanting to quit. On the contrary, our results show the association increased in magnitude for recall of more targeted and local information, which suggests it is more potent than mainstream advertising. This finding is supported by analyses presented elsewhere in this supplement.31 While it is possible that the observed relationship could be due to higher exposure to all types of advertising, it remained significant irrespective of how often advertising was noticed.

Aboriginal and Torres Strait Islander peoples perceive targeted messages to be more relevant and effective,14,15,30 which may affect the influence of these messages on relevant attitudes. Among Maori people in New Zealand, culturally relevant campaigns have been shown to prompt discussions about smoking32 — an indirect effect of advertising that increases interest in quitting.33 While there is clear justification for targeted messages, together with emerging evidence regarding their benefit, consideration must also be given to whether this strategy is an effective use of scarce resources.34

Elsewhere, attitudes and intentions have been found to be most strongly influenced by advertising that evokes an emotional response, such as graphic or story-based messages.6,25,35 Such messages are rated highly by Aboriginal and Torres Strait Islander people and non-Indigenous Australians alike,14 and may also be an effective way to reduce disparities in quitting.36 How to best balance mainstream and targeted (including locally led) advertising will be an important area for future research.

Warning labels

We found that forgoing cigarettes was strongly associated with wanting to quit, as has been found in other settings,37,38 and that smokers were more likely to forgo cigarettes in the period after plain packaging was mandated than before. Although our before and after samples were not in any way random, the evidence is supportive of health warnings and plain packaging playing a role in maintaining concern about smoking. This is one of the aims of Australia’s plain packaging legislation, which increased the size of graphic warning labels, stripped all branding and regulated a drab brown pack colour.12

There is recent evidence that plain packaging increases the salience and effectiveness of health warnings.39–41 Our findings confirm these findings in a minority population with a high smoking prevalence. Further, our finding that warning label recall was not socially patterned adds to scarce evidence on the socioeconomic impacts of graphic pack warning labels, which has been identified as an international priority for tobacco control research.6,42

News stories

Frequent recall of news stories was related to higher levels of worry about health and interest in quitting, which supports previous findings that news items can complement paid sources of communication.6,43 We found no evidence of a social gradient in recall of news stories; in fact, they were more likely to be noticed often by smokers from remote areas. Online platforms to share and discuss news could play an important role here, and have been used effectively for Aboriginal tobacco control news and advocacy efforts.44 Local stories and those about leaders and other role models may be particularly influential.45,46

Strengths and limitations

This article draws on data from a broadly representative national sample of Aboriginal and Torres Strait Islander smokers. The size of the sample has enabled us to consider subgroup analyses based on socioeconomic indicators and other participant characteristics, including remoteness of residence. The frequency at which health promotional materials were recalled is likely to have been inflated by biased recruitment of project sites that prioritised tobacco control and of participants who were more connected to the health service. Although this means we cannot generalise results about how often different types of advertising and information were recalled, it does not compromise the findings on whether more frequent recall is associated with relevant attitudes and intentions.

The main limitation of our study is its reliance on self-report of awareness. It does not incorporate more objective media market data, as these would not capture some of the local activity and would therefore have been a limited source of information beyond the main media markets. Awareness can be affected by opportunity for exposure, the potency of the material, and the openness of the individual to the message. While it is impossible to separate these entirely, it is possible to infer likely relative contributions. For example, warning labels on packs are roughly equally available (albeit affected by levels of consumption) and are of largely fixed (standardised) potency. Thus, differences in recall and reactions can be largely attributed to the openness of the individual to the label’s message. When assessing associations with attitudes or intentions, we adjusted for noticing other types of health information (to control for variability due to openness) and for socioeconomic indicators (to control for variability due to opportunity for exposure), with the rationale that associations independent of these influences were a better assessment of potency. However, campaign effects are difficult to disentangle from other tobacco control efforts and contextual factors,3 particularly when using cross-sectional data. As such, a multivariable model that considers these factors has been reported in detail elsewhere for the outcome of wanting to quit.31

Finally, we report adjusted analyses, which necessarily exclude a small proportion of smokers who declined to answer questions, answered “don’t know”, had not smoked in the past month or were surveyed at the first project site. While it is possible that the excluded participants differ from those who were included, the same pattern of results was observed for unadjusted associations (where there were fewer exclusions) and where outcomes with a high percentage of “don’t know” responses (eg, wanting to quit) were repeated with “don’t know” recoded as “no”.

With these limitations in mind, we found a clear link between more frequent recall of health information and attitudes that support quitting, including wanting to quit. Further research is required to assess whether more targeted information is better able to tap into relevant beliefs and subsequently increase quitting.

1 Exposure to health information in a national sample of Aboriginal and Torres Strait Islander smokers*

Health information exposure variables	% (frequency)†

Warning labels (in past month)
How often have you noticed the warning labels on packs your smokes are sold in?
Never	11% (164)
Almost never or sometimes	24% (378)
Often or very often	65% (1015)
Have the warning labels stopped you from having a smoke when about to?
Never noticed warning labels	10% (164)
Noticed warning labels but never stopped	55% (887)
Noticed warning labels and stopped at least once	34% (550)
News stories (in past 6 months)
How often have you seen or heard a news story about smoking or quitting?
Never	30% (477)
Almost never or sometimes	46% (738)
Often or very often	24% (386)
Advertising and information (in past 6 months)
How often have you noticed anti-tobacco advertising or information?
Never	15% (241)
Almost never or sometimes	40% (635)
Often or very often	45% (730)
Noticed any targeted advertising
Yes	48% (783)
No or never noticed advertising	46% (745)
Don’t know	6% (96)
Noticed any local advertising
Yes	16% (258)
No or never noticed mainstream or targeted advertising	74% (1195)
Don’t know	11% (171)
Did you notice advertising or information:‡
On television	82% (1327)
On the radio	43% (690)
On the internet, including social media sites	25% (390)
On outdoor billboards	45% (706)
In newspapers or magazines	47% (751)
On shop windows or in shops where tobacco is sold (at point of sale)	43% (679)
In leaflets or pamphlets	55% (877)
Posters or displays at local health service	74% (1186)
Posters or displays at other Aboriginal or Torres Strait Islander organisation	67% (1051)
Posters or displays at local festival or community event	59% (921)

* Results are from the Talking About The Smokes baseline sample of current smokers (n = 1643, or n = 1573 for questions regarding recall of warning labels). † Except where specified (for targeted and local advertising), percentages and frequencies exclude refused and “don’t know” responses, which accounts for differences in the total. ‡ Results are percentages of all smokers, including those who had never seen advertising or information in the past 6 months.

2 Association of health information exposure with attitudes in a national sample of Aboriginal and Torres Strait Islander smokers*

	Believe smoking is dangerous to others		Very worried smoking will damage own health		Believe mainstream society disapproves of smoking		Want to quit smoking
	% (frequency)†	AOR (95% CI)‡	% (frequency)†	AOR (95% CI)‡	% (frequency)†	AOR (95% CI)‡	% (frequency)†	AOR (95% CI)‡

Noticed warning labels (in past month)		P < 0.001		P < 0.001		P = 0.45		P < 0.001
Never	77% (126)	1.0	14% (22)	1.0	58% (95)	1.0	45% (71)	1.0
Sometimes	86% (325)	1.54 (0.93–2.56)	20% (75)	1.41 (0.81–2.44)	55% (209)	1.01 (0.67–1.54)	58% (204)	1.31 (0.82–2.07)
Often	94% (953)	3.56 (2.16–5.86)	44% (442)	3.44 (2.14–5.53)	64% (650)	1.21 (0.80–1.81)	78% (755)	2.90 (1.85–4.52)
Noticed news stories (in past 6 months)		P = 0.12		P = 0.002		P = 0.12		P = 0.03
Never	90% (427)	1.0	25% (118)	1.0	64% (306)	1.0	59% (271)	1.0
Sometimes	91% (668)	0.58 (0.35–0.97)	34% (250)	1.56 (1.16–2.08)	59% (438)	0.75 (0.56–1.00)	71% (491)	1.40 (1.07–1.82)
Often	93% (359)	0.67 (0.37–1.24)	49% (187)	1.84 (1.30–2.61)	66% (254)	0.73 (0.51–1.05)	81% (297)	1.61 (1.05–2.47)
Noticed advertising (in past 6 months)		P = 0.004		P < 0.001		P < 0.001		P = 0.002
Never	82% (197)	1.0	18% (42)	1.0	58% (139)	1.0	48% (112)	1.0
Sometimes	91% (580)	2.26 (1.31–3.88)	29% (179)	1.10 (0.70–1.73)	56% (356)	1.08 (0.74–1.57)	68% (403)	1.57 (1.12–2.18)
Often	94% (684)	2.78 (1.47–5.26)	47% (342)	2.02 (1.29–3.17)	70% (510)	2.07 (1.31–3.27)	79% (548)	2.17 (1.42–3.31)
Type of advertising (in past 6 months)§		P = 0.006		P = 0.25		P = 0.60		P < 0.001
Never noticed any advertising	82% (197)	1.0	18% (42)	1.0	58% (139)	1.0	48% (112)	1.0
Noticed mainstream (but no targeted) advertising	91% (522)	1.94 (1.09–3.46)	32% (181)	1.00 (0.62–1.60)	60% (345)	1.00 (0.67–1.48)	65% (354)	1.27 (0.91–1.78)
Noticed some targeted (but no local) advertising	93% (489)	2.58 (1.39–4.80)	43% (224)	1.15 (0.72–1.83)	66% (347)	1.13 (0.74–1.74)	77% (388)	1.99 (1.30–3.04)
Noticed some local advertising	95% (245)	3.63 (1.58–8.38)	44% (112)	1.34 (0.79–2.27)	66% (170)	1.24 (0.79–1.97)	84% (202)	2.88 (1.76–4.72)

AOR = adjusted odds ratio. * Results are based on the Talking About The Smokes project baseline sample of current smokers who had smoked in the past month (n = 1573). † Percentages and frequencies exclude refused and “don’t know” responses. ‡ AORs are adjusted for daily smoking status, key sociodemographic variables (age, sex, Indigenous status, labour force status, highest level of education, remoteness and area-level disadvantage), noticing other types of health information, and survey month (in 2-month blocks). P values are reported for overall variable significance, using adjusted Wald tests. § In addition to other covariates, analyses for type of advertising are also adjusted for frequency of advertising recall (often v sometimes or never).

Tobacco control policies and activities in Aboriginal community-controlled health services

Aboriginal community-controlled health services (ACCHSs) have long recognised tobacco use as an important contributor to poor health outcomes in their communities,1 and have worked to reduce this burden with a range of tobacco control initiatives. The ACCHS sector includes about 150 health services across Australia, each governed and managed by its local Aboriginal community, as well as representative state or territory organisations (Affiliates) and the National Aboriginal Community Controlled Health Organisation (NACCHO).

In 2001, NACCHO surveyed 67 staff from Aboriginal health services, 124 Aboriginal and Torres Strait Islander community members from 13 locations, and 76 health services with predominantly Aboriginal and Torres Strait Islander clients.2 The survey identified high levels of knowledge about the harmful health effects of tobacco, a lack of specific tobacco control programs and the need for more information on effective stop-smoking interventions. The report recommended that governments prioritise and fund tobacco control through policies that deal with social determinants of smoking, workforce training, comprehensive long-term programs to reduce smoking, and ongoing evaluation. For ACCHSs, the report recommended making tobacco control a specific priority and integrating it into health service programs.

Since 2001, specific tobacco control programs have been widely implemented in ACCHSs, informed by evidence from individual evaluations and randomised controlled trials of Aboriginal tobacco control interventions,3–5 and literature reviews.6–9 ACCHSs have also learnt from each other by sharing examples of what has (or has not) worked well.10–12

In 2008, the federal government increased support through the $14.5 million Indigenous Tobacco Control Initiative over 3 years, followed in 2009 by a $100.6 million commitment over 4 years to the Council of Australian Governments’ Tackling Indigenous Smoking measure.13,14 These funded social marketing, quit support and other programs, with the goal of halving smoking rates in Aboriginal and Torres Strait Islander communities by 2018. Forty ACCHSs and three NACCHO Affiliates received funds for tobacco control activities under these initiatives. Smoke-free workplace policies for ACCHSs and other organisations delivering Aboriginal primary health care were mandated in funding contracts with the Australian Government from July 2012.15

These tobacco control activities occurred in the wider Australian context of expanding smoke-free legislation, increases in tobacco taxation, plain packaging of cigarettes and ongoing social marketing campaigns.

The Talking About the Smokes (TATS) project, part of the International Tobacco Control Policy Evaluation Project, aims to assess the impact of tobacco control policies on the Aboriginal and Torres Strait Islander population. Here, we describe the tobacco control policies, activities and programs reported by the ACCHSs participating in the TATS project.

Methods

The TATS project involved 35 communities served by 34 ACCHSs and one community in the Torres Strait where there is no ACCHS and health services are provided by Queensland Health. ACCHSs were selected to reflect the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. The methods are described in detail elsewhere.16,17

Briefly, at 30 sites, we aimed to survey up to 50 smokers or ex-smokers who had quit ≤ 12 months before and 25 non-smokers, with equal numbers of men and women and those aged 18–34 years and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. Between April 2012 and October 2013, trained local interviewers completed the 30–60 minute community surveys face to face using a computer tablet. The community sample closely matched the distribution of age, sex, jurisdiction, remoteness and number of cigarettes smoked per day reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17

The TATS project also invited representatives at each site to complete a single policy monitoring survey, including questions about health service size and location; tobacco control funding, resources and policies; cessation support; and advocacy. The policy monitoring surveys were paper-based, designed to take less than 10 minutes, and were completed by staff members selected by the ACCHS. Policy monitoring surveys were completed while community surveys were being conducted at that site. Questions from the policy monitoring and community surveys analysed here are listed in Appendix 1.

Statistical analyses

We report the numbers of ACCHSs with different levels of tobacco control resourcing, activities and smoke-free policies; and the percentage and frequency of community members supporting smoking bans. Using the χ2 test, we assessed variation between services by size of service (< 50 or ≥ 50 staff); whether the service had received dedicated tobacco control funding in the past year; and its reported prioritisation of tobacco control in the past year (“not at all”, “just a little”, “a fair amount” or “a great deal”).

At the first project site, the question about prioritisation of tobacco control was not asked, and two questions about dispensing and prescribing free nicotine replacement therapy were asked as a single question. Less than 0.5% of respondents to the community survey did not answer the questions about smoking bans. These missing values were excluded from our analyses. We also excluded results from the Torres Strait community without an ACCHS.

Results

The 32 completed policy monitoring surveys describe tobacco control activities at 34 sites, as a single survey was completed by the umbrella ACCHS for three participating sites in one area. Nineteen services had 50 or more staff and 13 had fewer than 50.

Tobacco control resourcing and activities at ACCHSs

Nineteen of 32 ACCHSs reported receiving specific funding for tobacco control programs in the past 12 months. Another three used untied funds for tobacco control programs. Dedicated tobacco control funding was not associated with the size of the ACCHS (P = 0.84) or its reported prioritisation of tobacco control (P = 0.19). Thirteen ACCHSs reported prioritising tobacco control a great deal, 11 a fair amount and seven just a little. Eighteen ACCHSs had a staff position with a major focus on tobacco control.

Staff of 27 services had attended tobacco control training in the past year. There was no association between staff attending training and the size of the service (P = 0.31) or dedicated tobacco control funding (P = 0.34). However, there was an association with the prioritisation of tobacco control (P = 0.04), with some staff attending training at all 13 ACCHSs that had prioritised it a great deal. The training had been provided by a range of organisations, including NACCHO Affiliates, the Centre for Excellence in Indigenous Tobacco Control, cancer councils, quit organisations and state health departments.

In the past 12 months, 17 of 32 services had run programs to help people quit smoking. These included Aboriginal-specific tobacco control and healthy lifestyle programs, as well as mainstream quit programs. In all but one of these services, Aboriginal health workers or tobacco action workers were involved in running the program. Programs had been evaluated in nine services, some with internal surveys and others with the assistance of NACCHO Affiliates or universities.

Free nicotine replacement therapy was prescribed or dispensed by 25 of the 32 services. Most ACCHSs (21/34) supported staff who smoked by providing them with extra smoking cessation support, either by facilitating access to programs available to clients or through specific programs for staff.

Smoke-free workplace policies

All ACCHSs reported having a formal smoke-free policy in place. The features of these policies and the reported levels of adherence are described in Box 1. In contrast, only 18 of 32 services reported that most or all other Aboriginal and Torres Strait Islander organisations in their community were smoke-free; 10 reported that some were smoke-free and four that none were.

Community survey respondents (n = 2435) reported a high level of support for smoking bans everywhere at ACCHSs and indoors at other Aboriginal organisations, with less (but still majority) support for bans at outdoor community events (Box 2). Among the daily smokers who did not support total bans at ACCHSs, 82% (251/306) supported indoor bans. Daily smokers were least likely to support any of the bans.

Health promotion

All 32 ACCHSs provided locally or externally produced quit-smoking information to their communities, most commonly using posters, pamphlets and displays at information days or other community events, but also using newer media such as the internet and social media (Box 3). Health services with dedicated tobacco control funding were more likely to use locally developed posters (P = 0.03) and pamphlets (P = 0.02) in the clinic, and to give pamphlets to other organisations (P = 0.02), but there were no significant associations with funding when these locally developed items were considered together with externally developed information, or for other types of information. Ten services reported smoking or quitting stories featuring someone from their health service in mainstream or Aboriginal and Torres Strait Islander television, radio or newspaper news.

Nineteen ACCHSs reported discussing tobacco control policy at meetings with government and non-government organisations in the previous year, with 11 reporting that they had influenced local, regional or national tobacco control policy.

Discussion

We found that tobacco control initiatives are a priority in ACCHSs, with all reporting smoke-free workplace policies to reduce smoking and exposure to second-hand smoke. Staff with specific tobacco control training are providing a range of evidence-informed quit-smoking programs in health services and in the wider Aboriginal and Torres Strait Islander community. This increased tobacco control activity was not just found in health services with dedicated Aboriginal and Torres Strait Islander tobacco control funding.

Elsewhere in this supplement, we show that more community members from sites with dedicated tobacco control resources had been advised to quit,18 recalled noticing cigarette pack warning labels,19 made quit attempts20 and used stop-smoking medicines21 than those from sites without dedicated resources. However, there were no such significant differences for wanting to quit,22 smoke-free homes,23 recalling advertising and news stories about smoking and quitting,19 and personal attitudes towards smoking.24

A limitation to our study is that although the selected ACCHSs are geographically representative of the Aboriginal and Torres Strait Islander population, the ACCHSs that responded to the call for participation are likely to be biased towards those that were more interested and active in tobacco control. Further, the people completing the policy survey may have been unaware of all services and policies or may have overstated what was being provided. It was difficult to categorise services by their level of tobacco control activity because of the differences in the range of activities offered. Consequently, it was not possible to detect a relationship between dedicated funding and level of tobacco control activity. Furthermore, the small number of health services in our study did not allow identification of enablers and barriers to services prioritising tobacco control work, a useful area to explore in future research.

Our findings on smoke-free policies are not surprising, given implementing smoke-free work environments became a condition of funding for ACCHSs at the same time this study was conducted.15 However, it is likely that some aspects of these policies pre-dated the funding requirement, given that all 76 Aboriginal health services surveyed in 2001 reported indoor smoking bans, with the policies of 32% of services including broader measures.2 Our results provide evidence that many ACCHSs have more comprehensive policies, such as banning staff from smoking with clients and other staff or where they can be seen or while in uniform, and the provision of cessation support for staff. The incremental approach of ACCHSs in developing and strengthening policy content and implementation has common ground with government approaches to tobacco control, where success with indoor smoking bans was followed by an emphasis on initial exceptions, such as pubs and prisons, and on outdoor areas such as outdoor dining areas and street malls.25

The high level of community support for smoking bans that we found may reflect the wider tobacco control environment and the active involvement of ACCHS managers, staff and the community in tobacco control over the preceding decade. ACCHSs reported that policies relating to smoking behaviour of Aboriginal staff and the community have evolved over time, as the measures have been contested and negotiated in various Aboriginal community forums. This has included discussions about the right to smoke and the right to be protected from second-hand smoke, the social inclusion of sharing cigarettes and the significance of denormalising smoking and modelling healthier behaviour to children.11,26

The relatively small size of many ACCHSs provides an environment to test out policy measures that can then be either discarded as unacceptable or ineffective, or promoted as successful measures to other Aboriginal, community and health organisations. A key characteristic of ACCHSs is that a community with a high prevalence of smoking is involved in making and implementing decisions in areas they can control, such as workplaces and community events, thus providing Aboriginal leadership and contributing to shifts in social norms in their community. Aboriginal health services are well placed to influence social norms because of the large number of Aboriginal and Torres Strait Islander people who work there and use their services — 3618 full-time equivalent staff and 314 000 clients in 2012–13.27 There is an opportunity for ACCHSs to influence other Aboriginal and Torres Strait Islander organisations in their communities that do not have smoke-free policies.

It would be useful to monitor the diffusion of the successful and innovative tobacco control work both within and beyond the ACCHS sector, and to look to ACCHSs for new ideas in the future. The high level of commitment and experience in ACCHSs provides a strong base for sustainable interest and activity to further reduce smoking levels and smoking-related harm.

1 Smoke-free policies at health services (n = 32)

Policy details	Health services

Policy content
No smoking indoors	32
Designated outdoor smoking area	12
No smoking indoors or outdoors within the boundary/fence of health service	28
No smoking in work vehicles	32
No smoking in health service uniform	18
No smoking in work time	9
Other*	5
How the policy was communicated
Written policy	32
Signs	28
Staff meetings and/or newsletters	25
How many staff and clients follow all elements of the policy
Almost all	17
Most	11
Some	3
Only a few	1

* Such as no staff smoking with clients or other staff, when offsite in an official capacity or outside designated meal breaks.

2 Aboriginal and Torres Strait Islander community support for smoke-free environments (n = 2435)*

Smoking ban	Daily smokers (n = 1342)	Non-daily smokers (n = 233)	Ex-smokers (n = 299)	Never-smokers (n = 561)

Smoking should be banned everywhere at ACCHSs	77% (1030)	85% (197)	85% (255)	87% (487)
Smoking should be banned indoors at other Aboriginal organisations	93% (1242)	93% (217)	95% (284)	97% (544)
Smoking should be banned at outdoor festivals and sporting events	51% (687)	70% (163)	65% (194)	71% (398)

ACCHSs = Aboriginal community controlled health services. * Results are based on the respondents who “agree” or “strongly agree” with each statement and exclude those who did not answer.

3 Health services using different media to disseminate quit-smoking information (n = 32)

Quit-smoking information	Health services

Posters in clinic	31
Pamphlets in clinic	29
Health information days and events	28
Displays at other community events	26
Posters in other community locations	23
Pamphlets given to other organisations	21
Newsletters	18
Website	14
Social media	12
Newspaper or community magazine	11
Local radio advertisement	11
CD/DVD	11
Local television advertisement	2
Mobile phone messages	2

Social acceptability and desirability of smoking in a national sample of Aboriginal and Torres Strait Islander people

Smoking is partly motivated by social factors, although the strength of this influence has declined as smoking has become less socially normative in the community.1,2 Social norms have two aspects: social acceptability, or the contexts where the behaviour is accepted, and social desirability, or the extent to which it is valued. Separating the two can be difficult in practice.

Challenging normative beliefs was a focus of community-based programs to reduce the smoking rate and burden of tobacco-related disease among Aboriginal and Torres Strait Islander communities,3 as part of the 2009 National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.4 In particular, these programs tackled the social desirability and acceptability of smoking in contexts where the smoke affects other people. There has been very little published research to guide this approach.

In the broader Australian population, most smokers (86%) agree that society disapproves of smoking,5 which is an indication that smoking is no longer socially acceptable in certain situations. In contrast, the high prevalence of smoking in Aboriginal and Torres Strait Islander peoples (42% in those aged 15 years or older)6 contributes to beliefs that smoking is normal, expected or intergenerational.7–12 This suggests a certain level of acceptability but does not necessarily indicate whether smoking is socially desirable or valued.

The negative impact of tobacco use on Aboriginal and Torres Strait Islander families appears to reduce the desirability of smoking.7 In particular, the importance of protecting others from the harms of second-hand smoke and setting an example to children are said to provide strong motivation to quit.7,13,14 Parents, older relatives, health staff and elders have been identified as important anti-tobacco role models for Aboriginal and Torres Strait Islander youth.7–9

However, there is evidence that smoking is also valued within Aboriginal and Torres Strait Islander networks, among which smoking and sharing tobacco are associated with connectedness, affirmation of cultural identity and the opportunity to talk through problems.7,9,11–13,15,16 The strength of these competing values and their influence on quitting has not been previously investigated.

Here, we describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander peoples, and assess the relationship of these beliefs with quitting.

Methods

Survey design and participants

We used data from the Talking About The Smokes (TATS) project, which conducted baseline surveys of 2522 Aboriginal and Torres Strait Islander people (1643 current smokers, 311 ex-smokers and 568 never-smokers) from April 2012 to October 2013. The survey design and participants have been described in detail elsewhere.17,18

Briefly, the study used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. These project sites were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers (or ex-smokers who had quit ≤ 12 months previously) and a smaller sample of 25 non-smokers, with equal numbers of men and women, and those aged 18–34 and ≥ 35 years. The sample sizes were doubled in four major urban sites and the Torres Strait. People were excluded if they were less than 18 years old, were not usual residents of the area, were staff of the ACCHS, or were deemed unable to consent or complete the survey.

In each site, different locally determined methods were used to collect a representative, albeit non-random, sample. The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and number of cigarettes smoked per day (for current daily smokers). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17

ITC Project comparison sample

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Comparisons were made with smokers in the general Australian population using data from the Australian ITC project, which surveyed 1010 daily smokers between September 2011 and February 2012 (Wave 8.5). Participants of the Australian ITC project were recruited by random digit telephone dialling from within strata defined by jurisdiction and remoteness.19 While baseline surveys were completed over the telephone, follow-up surveys could be completed online. Our comparisons are for daily smokers only, due to slightly different definitions of non-daily smokers between the TATS project and ITC Project surveys.

Outcome measures

Survey questions were based on previous Australian ITC Project surveys, but with added questions about specific concerns and in language better reflecting Aboriginal and Torres Strait Islander colloquial speech. Eight questions assessed normative beliefs, all of which used a five-point scale ranging from “strongly agree” to “strongly disagree” (plus a “don’t know” response, which was later merged with “neither agree nor disagree”, and a “refused” option, which was excluded from analysis).

Two quit-related outcomes were used: wanting to quit, and having attempted to quit in the past year, which was derived from questions on ever having tried to quit and how long ago the most recent quit attempt occurred. The exact survey questions are presented in Appendix 1.

Statistical analyses

We calculated percentages and frequencies for all normative belief items. ITC Project data were summarised using percentages and 95% confidence intervals, directly standardised to match the age and sex profile of Aboriginal and Torres Strait Islander smokers according to the 2008 NATSISS.

For TATS project outcomes, variation by smoking status was investigated with simple logistic regression. Multivariable logistic regression was used to assess the association of each normative belief with wanting and attempting to quit, adjusted for daily smoking status and key sociodemographic variables. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the TATS Project sampling design, identifying the 35 project sites as clusters and the age–sex quotas as strata.20

For questions about normative beliefs, data were excluded for less than 1% of participants due to missing or refused responses. For associations with wanting to quit, we excluded a further 79 smokers (4.8%) who did not know if they wanted to quit; and for associations with quitting in the past year, we excluded 21 (1.3%) who did not know when their last quit attempt occurred (if ever).

Results

Normative beliefs

Aboriginal and Torres Strait Islander daily smokers were less likely than those in the general Australian population to perceive that mainstream society disapproves of smoking (62% v 78.5%) (Box 1). Among all Aboriginal and Torres Strait Islander respondents, higher proportions agreed that society disapproves of smoking than agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking (62% v 41%).

While similar proportions of daily and non-daily smokers agreed that mainstream society disapproves of smoking, non-daily smokers were more likely to agree that Aboriginal and Torres Strait Islander community leaders where they live disapprove (odds ratio [OR], 1.50; 95% CI, 1.10–2.05; P = 0.01). Close to two-thirds of smokers and recent quitters agreed there are now fewer places where they feel comfortable smoking, with little variation by smoking status. Although a minority of respondents said non-smokers miss out on all the gossip, this belief was more common among non-daily smokers (OR, 1.46; 95% CI, 1.01–2.10; P = 0.04) than daily smokers. Most Aboriginal and Torres Strait Islander respondents (90% or more) reported that being a non-smoker sets a good example to children, with no clear difference by smoking status. Finally, there was overwhelming support (80% or higher) for the government doing more to tackle the harm to Aboriginal and Torres Strait Islander peoples caused by smoking. This was significantly higher than the level of support for government action among the general Australian population (47.2%).

Few non-smokers said they were excluded by smokers or pressured by smokers to take up smoking (Box 2). Ex-smokers who had stopped smoking within the past year (but not those who had been quit for more than 1 year) were more likely to say they were pressured to smoke (OR, 1.99; 95% CI, 1.09–3.61; P = 0.04) than those who had never smoked.

Relationship between normative beliefs and quitting

Among smokers, all five anti-smoking beliefs were associated with wanting to quit, and all except perceived societal disapproval of smoking were also associated with having attempted to quit in the past year (Box 3). The only pro-smoking belief, that non-smokers miss out on all the gossip or yarning, was not associated with either wanting or attempting to quit.

Discussion

We found that Aboriginal and Torres Strait Islander smokers are less likely than smokers in the broader Australian population to believe that society views smoking as socially unacceptable. This difference is likely to be a product of higher smoking prevalence, but it may also reinforce it — lower perceived social acceptability of smoking was associated with wanting and attempting to quit, as has been found in other settings.21–24 In contrast, personal attitudes towards smoking (regretting starting to smoke, perceiving it to be too expensive, enjoying it, seeing it as an important part of life and smoking for stress management) do not appear to be driving differences in quitting.25

One possible interpretation of this pattern of results is that social norms are more influential in collectivist societies, in which behaviour is shaped to a greater degree by societal than personal needs.24,26,27 There is a growing body of evidence that protecting others provides strong motivation for Aboriginal and Torres Strait Islander peoples to quit,7,13,14,28 reflected here in the particular salience and influence of believing non-smokers set a good example to children. Similar findings were reported for Maori and Pacific peoples in the New Zealand ITC Project,26 which recommended greater emphasis on social reasons to quit, such as setting an example to children. For those who work in comprehensive primary health care settings, messages framed in ways that emphasise protecting others are likely to motivate quitting for Aboriginal and Torres Strait Islander peoples who smoke.

However, while this may be a more effective means of motivating people to quit, the implications for sustaining quit attempts are unclear. Current behaviour change theory suggests that quitting may be more difficult to sustain when motivated by social influences (including concern for others), given the likely challenges by internal needs such as biological or psychological dependence.2 General practitioners and others who provide cessation help should not discount the possibility that more dependent smokers may require support to manage cravings or urges to smoke upon quitting. Sustaining a quit attempt in the face of additional challenges, some of which are specific to the context of quitting for Aboriginal and Torres Strait Islander smokers, is an important area for future research.29

Our finding that quitting among Aboriginal and Torres Strait Islander smokers appears to be more influenced by their perceptions that local community leaders disapprove of smoking than by disapproval by mainstream society is important. In other settings, norms from significant others are more influential on cigarette consumption and motivation to quit than are mainstream societal norms.24 In this context, significant others may include distant relatives and respected community leaders, who have been described as influential in decisions about starting to smoke among Aboriginal and Torres Strait Islander youth.7–9 This offers one explanation for the motivational effect of local Aboriginal and Torres Strait Islander leaders, although we were unable to assess whether these constructs overlap.

Further, while the survey measured perceptions about disapproval of smoking by local leaders, our findings nonetheless have implications for tobacco control leadership, and the importance of community leadership in particular. We can draw from examples of indigenous leadership and participation across all areas of tobacco control in New Zealand,30 where strong national and local Maori leadership, targeted messages and Maori approaches are seen as critical for Maori tobacco-free advances.31 There are also an increasing number of examples of community leadership in Aboriginal and Torres Strait Islander tobacco control. A 2012–2013 survey of 47 Australian organisations involved in the development of tobacco control messages for Aboriginal and Torres Strait Islander peoples showed that 32% targeted elders in these messages.32 Social marketing and other strategies that directly involve local community leaders, or shift perceptions about the beliefs of community leaders, offer a means of reinforcing beliefs that smoking is socially unacceptable and therefore strengthening motivation to quit.

We found strong support for government action to tackle the harm caused by smoking. Resistance to tobacco control is therefore not a plausible explanation for differences in quitting between Aboriginal and Torres Strait Islander peoples and other Australians. There have been similar findings for other high-prevalence populations.33

Further, while smoking may be considered somewhat more normal among Aboriginal and Torres Strait Islander smokers, we found no evidence of social norms that indicate smoking is strongly socially valued or desirable. In contrast to previous evidence that suggests social isolation of non-smokers contributes to the high smoking prevalence among Aboriginal and Torres Strait Islander peoples,7,9,12,13,16 we found that most non-smokers did not feel excluded by smokers or pressured to smoke, or that they missed out on gossip. Further, even among smokers who believed that non-smokers missed out, we found no evidence that this presents a major barrier to quitting activity.

Strengths and limitations

The TATS project dataset provides the first national, broadly representative record of normative beliefs about smoking among Aboriginal and Torres Strait Islander smokers and non-smokers.

However, this study has some limitations. Analyses of associations between normative beliefs and quitting excluded 4.8% of smokers who did not know if they wanted to quit and 1.3% who could not recall how long ago their most recent quit attempt occurred. While this removes uncertainties regarding the categorisation of “don’t know” responses into yes/no outcomes, it also excludes a small proportion of Aboriginal and Torres Strait Islander people who may differ from included participants.

It is possible that we missed important normative beliefs that have additional influences. In particular, we did not ask specific questions about beliefs of family. This was because the diversity of family structures and a varying tendency to include distant relatives requires more extensive questioning than we had capacity for.

While it is possible that some of the differences found may be due to culturally moderated social desirability biases, we attempted to minimise the potential for this by engaging local interviewers.34 Tobacco control research in other settings suggests that survey responses about wanting to quit are not subject to greater social desirability biases when collected face to face.35

We also stress that the associations presented should not be interpreted as being causal. We cannot determine from these results alone whether negative beliefs about the social acceptability and desirability of smoking motivate quitting, or whether those motivated to quit are more likely to express negative views. While these limitations complicate our interpretations, the hypothesised causal links are strengthened by prospective research in other settings.21–24

Finally, comparisons with ITC Project data must be made with a degree of caution, given differences in methods and timing of recruitment and data collection. However, the differences we report here are too large to be accounted for by these factors.

In conclusion, tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.

1 Social normative beliefs about smoking among daily smokers in the Australian population and among a national sample of Aboriginal and Torres Strait Islander people, by smoking status*

	Australian ITC Project†	Talking About The Smokes project‡
Normative belief§	Daily smokers (n = 1010)	Daily smokers (n = 1392)	Non-daily smokers (n = 251)	Ex-smokers (n = 311)	Never-smokers (n = 568)

[Mainstream] society disapproves of smoking
Strongly agree or agree	78.5% (73.3%–82.9%)	62% (851)	65% (164)	62% (190)	62% (351)
Neither agree nor disagree, or don’t know	10.6% (7.9%–13.9%)	24% (336)	22% (56)	22% (67)	24% (138)
Disagree or strongly disagree	11.0% (7.4%–15.9%)	14% (196)	12% (31)	17% (52)	14% (78)
Aboriginal and/or Torres Strait Islander community leaders where you live disapprove of smoking
Strongly agree or agree	—	40% (547)	50% (124)	43% (133)	38% (218)
Neither agree nor disagree, or don’t know	—	33% (453)	24% (60)	29% (88)	36% (205)
Disagree or strongly disagree	—	28% (380)	26% (66)	28% (87)	26% (145)
There are fewer and fewer places you (would) feel comfortable smoking¶
Strongly agree or agree	—	70% (970)	65% (163)	65% (51)	—
Neither agree nor disagree, or don’t know	—	14% (192)	14% (35)	13% (10)	—
Disagree or strongly disagree	—	16% (220)	21% (52)	22% (17)	—
Non-smokers miss out on all the good gossip/yarning
Strongly agree or agree	—	27% (379)	36% (89)	29% (89)	23% (131)
Neither agree or disagree, or don’t know	—	18% (246)	16% (41)	8% (26)	14% (81)
Disagree or strongly disagree	—	55% (758)	48% (121)	63% (194)	63% (356)
Being a non-smoker sets a good example to children
Strongly agree or agree	—	90% (1246)	94% (236)	95% (292)	95% (541)
Neither agree nor disagree, or don’t know	—	5% (70)	2% (5)	2% (6)	3% (15)
Disagree or strongly disagree	—	5% (67)	4% (10)	4% (11)	2% (11)
The government should do more to tackle the harm [done to Aboriginal and Torres Strait Islander people] that is caused by smoking
Strongly agree or agree	47.2% (41.6%–52.8%)	80% (1108)	86% (215)	89% (270)	84% (465)
Neither agree nor disagree, or don’t know	21.6% (17.5%–26.3%)	13% (173)	9% (23)	6% (17)	12% (65)
Disagree or strongly disagree	31.3% (25.8%–37.3%)	7% (101)	5% (12)	6% (18)	4% (24)

ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses. † Results are percentages (95% confidence intervals) for daily smokers from Wave 8.5 (September 2011 – February 2012) of the Australian ITC Project, directly standardised to the age and sex of Aboriginal and Torres Strait Islander smokers surveyed in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results are percentages (frequencies) for the baseline sample of Aboriginal and Torres Strait Islander people in the Talking About The Smokes project (April 2012–October 2013). § Text in square brackets was not included in Australian ITC Project survey questions. ¶ Asked of smokers and recent quitters only.

2 Social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander non-smokers*

Normative belief	Ex-smokers quit ≤ 1 year (n = 78)	Ex-smokers quit > 1 year (n = 233)	Never-smokers (n = 568)

You are excluded from things because you are a non-smoker (now)
Strongly agree or agree	27% (21)	25% (58)	24% (137)
Neither agree nor disagree	8% (6)	6% (14)	13% (73)
Disagree or strongly disagree	65% (51)	69% (159)	63% (358)
You are pressured by smokers to take up smoking (again)
Strongly agree or agree	26% (20)	13% (29)	15% (84)
Neither agree nor disagree	3% (2)	4% (10)	8% (43)
Disagree or strongly disagree	72% (56)	83% (192)	78% (441)

* Results are percentages (frequencies) for the baseline sample in the Talking About The Smokes project (April 2012–October 2013) and exclude refused responses.

3 Association of social normative beliefs about smoking with wanting and attempting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*

	Want to quit			Attempted to quit in the past year
Normative belief	% (frequency)†	Adjusted OR (95% CI)‡	P§	% (frequency)†	Adjusted OR (95% CI)‡	P§

Mainstream society disapproves of smoking
Neutral or disagree	65% (374)	1.0	0.01	46% (279)	1.0	0.05
Agree	73% (709)	1.49 (1.10–2.01)		51% (514)	1.26 (1.00–1.60)
Aboriginal and/or Torres Strait Islander community leaders where you live disapprove of smoking
Neutral or disagree	64% (578)	1.0	< 0.001	46% (431)	1.0	0.001
Agree	77% (504)	1.94 (1.50–2.52)		54% (360)	1.43 (1.16–1.77)
There are fewer and fewer places you feel comfortable smoking
Neutral or disagree	64% (302)	1.0	0.01	46% (224)	1.0	0.03
Agree	72% (781)	1.45 (1.09–1.93)		51% (569)	1.33 (1.03–1.71)
Non-smokers miss out on all the good gossip/yarning
Neutral or disagree	70% (769)	1.0	0.95	49% (564)	1.0	0.70
Agree	70% (314)	1.01 (0.75–1.36)		50% (229)	1.05 (0.82–1.34)
Being a non-smoker sets a good example to children
Neutral or disagree	37% (54)	1.0	< 0.001	33% (50)	1.0	0.001
Agree	73% (1029)	4.92 (2.98–8.12)		51% (743)	2.11 (1.37–3.24)
The government should do more to tackle the harm done to Aboriginal and Torres Strait Islander people that is caused by smoking
Neutral or disagree	51% (149)	1.0	< 0.001	42% (129)	1.0	0.009
Agree	74% (934)	3.03 (2.17–4.23)		51% (663)	1.48 (1.10–1.98)

OR = odds ratio. * Results are based on the baseline sample of current smokers (n = 1643) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses (for all variables) and “don’t know” responses (for quitting outcomes only). ‡ ORs are adjusted for daily smoking status and key sociodemographic variables (age, sex, identification as Aboriginal and/or Torres Strait Islander, labour force status, highest level of education, remoteness and area-level disadvantage). § P values are reported for overall variable significance, using adjusted Wald tests.

Personal attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters

Contemporary theories of smoking and other addictive behaviours see attitudes as one set of forces influencing behaviour.1,2 Negative attitudes towards smoking, such as those about its high cost or regret about starting to smoke, are associated with increased interest in quitting and attempts to quit,3–5 but perhaps not with sustained abstinence.6,7 These attitudes compete with the benefits attributed to smoking, which have been shown to predict continued smoking and relapse.8–10 Identifying attitudes that influence behaviour contributes to our understanding of what motivates and sustains quitting. This may differ between social and cultural environments, affecting which tobacco control policies work to reduce smoking.4,11

There is no nationally representative research that explores attitudes towards smoking among Aboriginal and Torres Strait Islander people. It is plausible that part of the reason for the high daily smoking prevalence, which was over double that of the non-Indigenous population in 2012–2013,12 is that Aboriginal and Torres Strait Islander people hold more positive attitudes and/or fewer negative beliefs about smoking. It is also theorised that thoughts about quitting may be cast aside in stressful circumstances, when motivation shifts from future goals to immediate priorities,2,13 which may be seen to be alleviated by benefits of smoking. Benefits of smoking described by Aboriginal and Torres Strait Islander peoples include coping with stress,14–21 providing belonging and connectedness,15,17,19–22 reinforcing sharing and reciprocity,15,17,19,21 and creating opportunities for yarning or talking through problems.14,15,17,19–21 Though concern about the high cost of smoking does not feature heavily in Aboriginal tobacco control literature, it is reported as one of the top motivators to quit among the general Australian population.23

Here, we describe attitudes towards smoking among a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters, assess their association with quitting among smokers, and compare these attitudes with those among smokers in the general Australian population.

Methods

Survey design and participants

The Talking About The Smokes (TATS) project surveyed 1643 current smokers and 78 ex-smokers who had quit ≤ 12 months previously, from April 2012 to October 2013 (Wave 1, or baseline). The survey design and participants are described in detail elsewhere.24,25

Briefly, the study used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait (project sites), which were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview a sample of 50 smokers or recent quitters (those who had quit within the past 12 months), with equal numbers of men and women, and those aged 18–34 years and ≥ 35 years. The sample sizes were doubled in four large city sites and in the Torres Strait community. People were excluded if they did not identify as Aboriginal or Torres Strait Islander, were less than 18 years old, were not usual residents of the area, were staff of the ACCHS, or were deemed unable to complete the survey. In each location, different locally determined methods were used to collect a representative, albeit non-random, sample (eg, surveying Aboriginal or Torres Strait Islander households, opportunistic event-based sampling, snowball sampling using established contacts).

Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, took 30–60 minutes to complete. The baseline sample closely matched the distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and also for number of cigarettes smoked per day (for current daily smokers). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.24 A single survey of health service activities was also completed for each site.

ITC Project comparison sample

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Comparisons were made with results from the Australian ITC Project, which surveyed 1017 daily smokers between July 2010 and May 2011 (Wave 8), and 1010 daily smokers between September 2011 and February 2012 (Wave 8.5). Participants of the Australian ITC Project were adult smokers who were recruited by random digit telephone dialling from within strata defined by jurisdiction and remoteness.26,27

The ITC Project sample mostly comprised those recontacted from previous survey waves, in addition to smokers who were newly recruited to replace those lost to follow-up (Wave 8, 14.6%; Wave 8.5, 17.8%). While baseline surveys were completed over the telephone, follow-up surveys could be self-administered online (Wave 8, 29.6%; Wave 8.5, 32.1%). Slightly different definitions of smokers between the TATS project and ITC Project surveys meant that only daily and weekly smoker categories were directly comparable. We have concentrated on daily smokers in our analyses.

Outcome measures

Survey questions were based on ITC Project surveys, particularly the Australian ITC Project surveys. The exact questions used for this article are presented in Appendix 1.

Eight questions measured attitudes towards smoking, all of which captured responses using a five-point scale from “strongly agree” to “strongly disagree” (plus a “don’t know” response, which was later merged with “neither agree nor disagree”). Five of these questions are reported here for smokers, and three for recent quitters.

Two outcomes were used to assess quitting: wanting to quit, and having attempted to quit in the past year, which was derived from questions on ever having tried to quit and how long ago the most recent quit attempt occurred.

Statistical analyses

We summarised the TATS project and ITC Project survey results using descriptive statistics. ITC Project data were directly standardised to match the age and sex profile of Aboriginal and Torres Strait Islander smokers according to the 2008 NATSISS. Given that our sample was not randomly selected, we did not calculate standard errors for comparisons of percentages between our data and ITC Project data. Thus, these comparisons do not incorporate calculations for statistical significance, but consider differences that are large and meaningful.

For smokers, we used logistic regression to analyse the five attitudinal outcomes and two outcomes on quitting. Unadjusted odds ratios (ORs) are reported for the five personal attitudes (dichotomised), by daily smoking status, sociodemographic variables, and presence of tobacco control resources at the local health service. For the outcomes on quitting, we report adjusted ORs for the five personal attitudes, controlling for daily smoking status and sociodemographic variables. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the TATS project sampling design in all tests of association, using Stata’s svyset command to identify the 35 project sites as clusters and the quotas based on age and sex as strata.28

Data for less than 1% of participants were excluded due to missing or refused responses. For the associations with wanting to quit, we excluded a further 79 participants (4.8%) who did not know if they wanted to quit, and for associations with quitting in the past year, we excluded 21 (1.3%) who did not know when their last quit attempt occurred (if ever).

Results

Attitudes held by smokers

Comparison with ITC Project data

Most attitudes among Aboriginal and Torres Strait Islander smokers were similar to those assessed for smokers in the general Australian population (Box 1). Most daily smokers reported regret about ever starting to smoke (TATS, 78%; ITC, 81.8%) and agreed that they spent too much money on cigarettes (TATS, 81%; ITC, 83.6%). A lower proportion of Aboriginal and Torres Strait Islander daily smokers (65%) than those in the general Australian population (80.6%) said they enjoyed smoking (Box 1). Though similar proportions of daily smokers agreed that smoking is an important part of their life (TATS, 32%; ITC, 34.6%), a higher proportion of Aboriginal and Torres Strait Islander respondents disagreed with this statement (TATS, 49%; ITC, 37.9%). A high proportion of daily smokers agreed that smoking calms them down when stressed or upset (TATS, 83%; ITC, 80.3%).

Attitudes of Aboriginal and Torres Strait Islander smokers

Non-daily smokers generally held less positive attitudes towards smoking (Appendix 2); compared with daily smokers, they were significantly less likely to say that they enjoy smoking (OR, 0.56; 95% CI, 0.42–0.75; P < 0.001), that smoking is an important part of their life (OR, 0.53; 95% CI, 0.35–0.81; P = 0.004) and that smoking calms them down when stressed (OR, 0.48; 95% CI, 0.35–0.67; P < 0.001). Non-daily smokers were also less likely to report that they spend too much money on cigarettes (OR, 0.28; 95% CI, 0.20–0.39; P < 0.001).

There was little variation in smoker attitudes by sociodemographic and other factors (Appendix 2). Compared with the youngest smokers, those aged 35–44 years were less likely to say they enjoy smoking (OR, 0.64; 95% CI, 0.43–0.93), whereas older smokers were more likely to report that smoking is an important part of their life (P < 0.001). Smokers from areas of the highest level of disadvantage were more likely to report that they enjoy smoking (OR, 1.66; 95% CI, 1.19–2.30) compared with those from the least disadvantaged areas (P = 0.01). Smokers from regional areas (OR, 1.67; 95% CI, 1.27–2.20) and remote or very remote areas (OR, 2.13; 95% CI, 1.49–3.04) were also more likely than those from major cities to report that they enjoy smoking (P < 0.001). Smokers who were not in the labour force (OR, 1.78; 95% CI, 1.32–2.38) were more likely to see smoking as an important part of their life than those who were employed (P < 0.001).

Attitudes about regretting ever starting to smoke, being calmed by smoking when stressed, and spending too much money on cigarettes did not vary according to sociodemographic indicators.

Relationship of smoker attitudes with quitting

The likelihood of wanting to quit or having attempted to quit in the past year was higher for Aboriginal and Torres Strait Islander smokers who regretted starting to smoke and those who said they spend too much money on cigarettes, and lower for smokers who said they enjoy smoking and those who reported that smoking is an important part of their life (Box 2).

Attitudes held by recent quitters

Ex-smokers who had quit within the past 12 months reported positive views about having quit (Box 3). Among these recent quitters, 87% agreed that they have more money since they quit, 74% agreed that they cope with stress at least as well as they did when smoking, and 90% agreed that their life is better now that they no longer smoke.

Discussion

Our results show that Aboriginal and Torres Strait Islander people were less likely than the general Australian population to report positive reasons to smoke and held similar views about the negative aspects of smoking. As negative attitudes to smoking were already common, approaches that seek to change these beliefs are not likely to affect Aboriginal and Torres Strait Islander smoking or quitting rates. In particular, levels of regret for ever starting to smoke were comparable to those seen globally.5,29 We hope this energises and reassures those in comprehensive primary health care settings who face the challenge of prioritising smoking cessation amid other, often pressing, demands.30

It is encouraging that a majority of smokers rejected the idea that smoking is an important part of their life, and that a lower proportion of Aboriginal and Torres Strait Islander smokers compared with those in the general Australian population said they enjoy smoking. As in other populations, smokers who agreed with statements about positive attributes of smoking were less interested in quitting and less likely to attempt to quit.10,31 The ITC Project has found that smokers who hold these positive attitudes are also less likely to quit successfully, but that part of this effect can be explained by differences in measures of nicotine dependence.10 However, factors that predict successful quitting sometimes differ from those that predict quit intentions and attempts.6,7 The complex relationships between attitudes, other factors and successful quitting is an important topic for future prospective research in this population.

Qualitative research has demonstrated broad recognition among Aboriginal and Torres Strait Islander peoples that stress is both a trigger for smoking and a common cause of relapse,14–17,19–21 consistent with international evidence on smoking for stress management.9,10 While we were surprised to find that those who believe smoking reduces their stress were no less motivated to quit, our outcomes were limited to quit attempts and not the success of such attempts. Connections between smoking and stress, or psychological reactions to stress, would benefit from further study using measures shown to be sensitive to the multiple life stressors and high levels of psychological distress experienced by Aboriginal and Torres Strait Islander peoples.32,33 Exploration of supports and strategies that enable successful quitting in the presence of these stressors is also indicated. Research on resilience to stress describes the pride associated with mastering the transition to becoming a non-smoker.16 In our results, most ex-smokers agreed that they cope with stress at least as well as they did when smoking and that their life is better now that they no longer smoke. The reduction in psychological distress that follows quitting is well documented.34,35 Health professionals and cessation resources could work towards extinguishing the myth that smoking reduces stress by replacing it with a more accurate and empowering message that ex-smokers experience less stress and greater quality of life once they quit.

Strengths and limitations

This article provides a broadly nationally representative snapshot of attitudes towards smoking held by Aboriginal and Torres Strait Islander smokers. The use of single items to measure constructs can lack sensitivity but enabled us to enquire about a broad range of topics, using attitudinal and functional utility items that have established validity in other populations.36 While the validity of these items is yet to be established for Aboriginal and Torres Strait Islander peoples, comparable associations with quit-related outcomes provide some evidence of convergent validity.36 However, the limited number of closed-ended questions used here would not have captured the full range of attitudes held by Aboriginal and Torres Strait Islander smokers and may have missed important constructs.

Further, comparisons with ITC Project data must be made with a degree of caution. There is expert consensus that response styles are culturally moderated, meaning that the degree to which social desirability bias affects the tendency to agree or respond using scale extremities can vary according to respondent characteristics.36 Methods of recruitment and data collection also differ between the TATS and ITC projects, which may affect response biases present in each. However, the degree of variation to responses across the eight attitude items provides some evidence against any systematic response preference or bias in our data.

Finally, these results do not provide information about whether negative attitudes towards smoking precede quitting, or whether those who are already making quit attempts tend to develop more negative views about smoking. Our understanding of the likely direction of these relationships is informed by prospective research from other settings, which can be tested using longitudinal data from the follow-up of these baseline results.

With these limitations in mind, our findings add to our understanding of the context of smoking and quitting for Aboriginal and Torres Strait Islander peoples. The finding that their personal attitudes towards smoking are similar to those among the general Australian population, and appear to share the same motivating effects, suggests factors other than personal attitudes are likely to explain the high prevalence of smoking among Aboriginal and Torres Strait Islander people. Future research should consider the effect of structural factors, such as access to services that support quitting, intergenerational effects of colonisation and dispossession, levels of racism and psychological distress, and normalisation of smoking within Aboriginal and Torres Strait Islander social networks.17,19,22,37–39

1 Attitudes towards smoking among smokers in the Australian population and a national sample of Aboriginal and Torres Strait Islander people*

	Australian ITC Project†	Talking About The Smokes project‡
Survey question and response	Daily smokers, % (95% CI)	Daily smokers, % (frequency)	Non-daily smokers, % (frequency)

If you had to do it over again, you would not have started smoking§
Strongly agree or agree	81.8% (75.7%–86.6%)	78% (1081)	79% (197)
Neither agree nor disagree	6.8% (4.3%–10.7%)	7% (102)	9% (23)
Disagree or strongly disagree	11.4% (7.3%–17.3%)	15% (200)	12% (30)
You spend too much money on cigarettes¶
Strongly agree or agree	83.6% (78.4%–87.6%)	81% (1116)	54% (134)
Neither agree nor disagree	7.4% (5.0%–11.0%)	8% (110)	11% (28)
Disagree or strongly disagree	9.0% (5.9%–13.5%)	11% (156)	35% (87)
You enjoy smoking§
Strongly agree or agree	80.6% (75.8%–84.6%)	65% (898)	51% (127)
Neither agree nor disagree	10.1% (7.5%–13.6%)	19% (261)	20% (49)
Disagree or strongly disagree	9.3% (6.3%–13.4%)	16% (223)	29% (73)
Smoking is an important part of your life§
Strongly agree or agree	34.6% (29.8%–39.9%)	32% (444)	20% (50)
Neither agree nor disagree	27.4% (22.5%–33.0%)	19% (268)	12% (30)
Disagree or strongly disagree	37.9% (32.5%–43.6%)	49% (670)	68% (169)
Smoking calms you down when you are stressed or upset¶
Strongly agree or agree	80.3% (75.5%–84.3%)	83% (1143)	70% (174)
Neither agree nor disagree	11.0% (7.7%–15.7%)	9% (127)	13% (33)
Disagree or strongly disagree	8.7% (6.6%–11.2%)	8% (111)	17% (42)

ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses. † Results for daily smokers from Wave 8 (n = 1017) or Wave 8.5 (n = 1010) of the Australian ITC Project, directly standardised to the age and sex of Aboriginal and Torres Strait Islander smokers surveyed in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results for the baseline sample of Aboriginal and Torres Strait Islander daily smokers (n = 1392) and non-daily smokers (n = 251) in the Talking About The Smokes project, April 2012 – October 2013. § Australian ITC Project Wave 8.5, September 2011 to February 2012. ¶ Australian ITC Project Wave 8, July 2010 to May 2011.

2 Association of personal attitudes towards smoking with wanting and attempting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*

	Want to quit			Attempted to quit in the past year
Attitude	% (frequency)†	Adjusted OR (95% CI)‡	P§	% (frequency)†	Adjusted OR (95% CI)‡	P§

If you had to do it over again, you would not have started smoking
Neutral or disagree	52% (176)	1.0	< 0.001	38% (131)	1.0	< 0.001
Agree	75% (907)	2.79 (1.96–3.97)		53% (662)	1.84 (1.37–2.48)
You spend too much money on cigarettes
Neutral or disagree	59% (204)	1.0	< 0.001	45% (167)	1.0	0.02
Agree	73% (879)	2.22 (1.59–3.10)		51% (626)	1.41 (1.06–1.88)
You enjoy smoking
Neutral or disagree	85% (489)	1.0	< 0.001	58% (348)	1.0	< 0.001
Agree	61% (594)	0.29 (0.21–0.42)		44% (445)	0.56 (0.44–0.70)
Smoking is an important part of your life
Neutral or disagree	75% (805)	1.0	< 0.001	53% (591)	1.0	0.001
Agree	59% (278)	0.48 (0.37–0.63)		41% (202)	0.68 (0.55–0.86)
Smoking calms you down when you are stressed or upset
Neutral or disagree	70% (203)	1.0	0.75	46% (140)	1.0	0.09
Agree	70% (880)	1.06 (0.75–1.51)		50% (653)	1.28 (0.97–1.69)

OR = odds ratio. * Results are based on the baseline sample of current smokers (n = 1643) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses (for all variables) and “don’t know” responses (for quitting outcomes only). ‡ ORs are adjusted for daily smoking status and key sociodemographic variables (age, sex, identification as Aboriginal and/or Torres Strait Islander, labour force status, highest level of education, remoteness and area-level disadvantage). § P values are reported for overall variable significance, using adjusted Wald tests.

3 Attitudes towards smoking and quitting among recent quitters in a national sample of Aboriginal and Torres Strait Islander people*

Survey question and response

% (frequency)†

Since you quit you have more money

Strongly agree or agree

87% (68)

Neither agree or disagree (or don’t know)

8% (6)

Disagree or strongly disagree

5% (4)

You can now cope with stress as well as you did when you were smoking

Strongly agree or agree

74% (57)

Neither agree or disagree (or don’t know)

12% (9)

Disagree or strongly disagree

14% (11)

Your life is better now that you no longer smoke

Strongly agree or agree

90% (70)

Neither agree or disagree (or don’t know)

8% (6)

Disagree or strongly disagree

3% (2)

* Results for the baseline sample of Aboriginal and Torres Strait Islander ex-smokers who had quit within past ≤ 12 months (n = 78) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses.