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

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

Questions on health information exposure

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

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

Main outcome measures and covariates

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

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

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

Statistical analyses

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

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

Results

Recall of health information

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

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

Associations with attitudes and wanting to quit

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

Outcomes for warning labels before and after plain packaging

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

Discussion

Advertising and information

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

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

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

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

Warning labels

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

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

News stories

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

Strengths and limitations

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

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

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

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

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

Health information exposure variables	% (frequency)†

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

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

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

	Believe smoking is dangerous to others		Very worried smoking will 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.

Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people

Fifty years since the United States Surgeon General’s first report on smoking and health, smoking prevalence has reduced globally,1 in part due to increased public awareness that smoking causes death and disease.2,3 However, it is possible that gaps in knowledge are contributing to health inequalities.4,5 In Australia, the prevalence of daily smoking has declined to just over 16% among adults but is higher in disadvantaged populations.6 Among the Aboriginal and Torres Strait Islander population, 42% of people aged 15 years or older smoked daily in 2012–2013.7 Understanding and tackling the causes of this disparity is a public health priority accepted by all Australian governments.8

Communicating information about the harmful effects of tobacco use is a major focus of programs to reduce smoking among Aboriginal and Torres Strait Islander peoples.9 Some evidence suggests that most Aboriginal and Torres Strait Islander people know that smoking causes lung cancer and heart disease,10–12 and that second-hand smoke (SHS) is dangerous.13–15 However, there is no current national research that describes knowledge of the harms of smoking and SHS exposure among Aboriginal and Torres Strait Islander smokers, or how it varies across this diverse population. Further, the extent to which lack of smoking-related knowledge contributes to the high smoking prevalence is unknown.

Greater knowledge and worry about future health effects of smoking have been shown to increase quit intentions and attempts in other settings.16–18 However, decisions to quit smoking are not one-dimensional, rational choices,19,20 and they may be obstructed by beliefs that diminish the likelihood or severity of smoking harms (risk minimisation).21,22 There has been some investigation into risk-minimising beliefs in Aboriginal and Torres Strait Islander tobacco control research. For example, perceived risk and worry may be low where there is discordance between information about the health consequences of smoking and the individual’s lived experience,14,23 or where there are fatalistic views of health effects that are perceived to be outside an individual’s control.12,24 This may explain why smoking persists in some contexts where knowledge of health effects is found to be high.

This is the first broadly representative description of smoking-related knowledge and health risk beliefs of Aboriginal peoples and Torres Strait Islanders. We also look at how this knowledge varies among smokers, and whether knowledge and health risk beliefs are related to quitting.

Methods

Survey design and participants

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people (1643 current smokers, 311 ex-smokers and 568 never-smokers) from April 2012 to October 2013 (Wave 1, or baseline), and is described in detail elsewhere in this supplement.25,26 Briefly, we used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait (project sites), which were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview samples of 50 smokers (or ex-smokers who had quit ≤ 12 months before) and 25 non-smokers (never-smokers and ex-smokers who had quit > 12 months previously), with equal numbers of men and women and those aged 18–34 years and 35 years or older. The sample sizes were doubled in four major urban sites and in the Torres Strait community. People were excluded if they were: not Indigenous, not aged 18 years or older, not usual residents of the area, staff members of the ACCHS, or unable to complete the survey in English (if there was no interpreter available), or if the quota for the relevant age–sex–smoking category had been filled.

In each site, different locally determined methods were used to collect a representative, albeit non-random, sample. The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and also number of cigarettes smoked per day for current daily smokers. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.25

Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, generally took 30–60 minutes to complete. A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed for each site. The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees (Appendix 1).25

Survey questions

As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), survey questions were based on ITC Project surveys previously used in Australia and New Zealand (http://www.itcproject.org/surveys). The exact questions used for this article are listed in Appendix 2.

Knowledge and health risk beliefs

Four questions assessed knowledge of the direct health effects of smoking among smokers and non-smokers — whether it causes lung cancer, causes heart disease, makes diabetes worse and causes low birthweight (answer options: “yes”, “no” or “don’t know”). Three questions assessed knowledge of the effects of SHS exposure — whether it causes asthma in children (“yes”, “no” or “don’t know”) and whether it is dangerous to non-smokers and to children (both assessed on a five-point scale from “strongly agree” to “strongly disagree”). We also computed two summary items, for correct responses to all four direct effects questions (“yes” to all) and correct responses to all three SHS measures (“yes” or at least “agree”).

Two items assessed health risk beliefs among smokers. Smokers who responded “agree” or “strongly agree” to the statement that “Smoking is not very risky when you think about all the things that people do” (assessed on a five-point scale from “strongly agree” to “strongly disagree”) were assessed as holding risk-minimising beliefs. Those who responded “very worried” to the question “How worried are you that smoking will damage your health in the future?” (assessed on a four-point scale from “not at all worried” to “very worried”) were assessed as having health worry.

Wanting and attempting to quit

Two quit-related outcomes were used: wanting to quit (“yes” or “no”) and having attempted to quit in the past year (“yes” or “no”), which was derived from questions on ever having tried to quit and timing of the most recent quit attempt.

Statistical analyses

Percentages and frequencies were calculated for all knowledge and health risk belief questions. Logistic regression was used to assess: (i) variation in correct responses among smokers, by daily smoking status, key sociodemographic variables, and presence of tobacco control resources at the local health service; and (ii) the association of knowledge and health risk beliefs with quitting interest and activity among smokers. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, identifying the 35 project sites as clusters, and the quotas based on age, sex and smoking status as strata.27 Both unadjusted and adjusted logistic regression analyses were performed, with daily smoking status and key sociodemographic variables included as covariates in the adjusted analyses. As unadjusted and adjusted calculations were very similar, only adjusted odds ratios (ORs) are reported here, with 95% confidence intervals.

Less than 1.5% of responses to each question were excluded (due to missing or refused responses), with the exception of quitting outcomes, which excluded a further 79 participants (4.8%) who did not know if they wanted to quit and 21 (1.3%) who did not know whether they had attempted to quit within the past year.

Results

Knowledge and health risk beliefs

Knowledge that smoking causes lung cancer and heart disease was high, and consistently over 90% of smokers and non-smokers knew about the harmful effects of SHS (Box 1). Knowledge that smoking makes diabetes worse was the lowest of all four direct effects, with 24% of daily smokers responding “don’t know” to this question (compared with 13% for low birthweight, 7% for heart disease and 3% for lung cancer). Among daily smokers, 44% held risk-minimising beliefs and 36% had health worry. Non-daily smokers had higher levels of risk-minimising beliefs and lower levels of health worry than did daily smokers.

Compared with daily smokers, non-daily smokers were more likely to respond correctly to all questions about the direct effects of smoking (OR, 1.79; 95% CI, 1.32–2.43; P < 0.001) and the harms of SHS (OR, 1.69; 95% CI, 1.08–2.62; P = 0.02) (Appendix 3).

There was some social patterning based on sociodemographic variables (Appendix 3). While knowledge of direct effects was significantly associated with employment and education, only area-level indicators were associated with both direct effects and SHS knowledge. Smokers were more likely to respond correctly to all questions if they were from a remote or very remote area (direct effects OR, 1.73; 95% CI, 1.16–2.57; SHS OR, 2.69; 95% CI, 1.61–4.52), compared with those from major cities, and smokers from an area of the highest level of disadvantage were more likely to respond correctly (direct effects OR, 1.83; 95% CI, 1.32–2.54; SHS OR, 1.33; 95% CI, 0.85–2.08) than were those from areas of least disadvantage.

Conversely, smokers from areas where the local health service had dedicated tobacco control staff or funding were less likely to respond correctly to all direct effects questions (OR, 0.64; 95% CI, 0.48–0.86) and all questions about the harms of SHS (OR, 0.58; 95% CI, 0.40–0.82), compared with those from areas where there were no dedicated resources (Appendix 3).

Relationship of knowledge and health risk beliefs with quitting

Smokers who responded correctly to all questions about harms of SHS were more likely to want to quit and to have attempted to quit in the past year, but those who responded correctly to questions about direct effects of smoking were not (Box 2). Similarly, smokers who responded correctly to all SHS knowledge questions were more likely to be very worried about their future health (OR, 4.74; 95% CI, 3.01–7.45; P < 0.001), but those with knowledge of all direct effects were not (Appendix 4). Those who were very worried about their health were more likely to want to quit and to have made a quit attempt in the past year (Box 2). Risk-minimising beliefs were not significantly associated with either wanting to quit or having attempted to quit in the past year.

Discussion

Our results show high levels of knowledge among Aboriginal and Torres Strait Islander people that smoking causes lung cancer and heart disease, along with strong awareness of the harms of SHS, consistent with previous tobacco control research in this population.10–14 Knowledge that smoking causes lung cancer and heart disease and is dangerous to others was assessed at very similar levels among Aboriginal and Torres Strait Islander daily smokers and those in the general population, based on comparable measures last assessed by Australian ITC Project surveys from 2002 to 2004.16,28

The main gap in knowledge, which has also been reported elsewhere,12 concerned the role of smoking in exacerbating diabetes. As Aboriginal and Torres Strait Islander people are more than three times as likely as non-Indigenous Australians to report a diagnosis of diabetes or high blood or urine sugar levels,7 with diabetes prevalence estimates ranging from 3.5% to 33.1%,29 this gap highlights the need for targeted education about the link between smoking and diabetes. This applies to clinicians as well as the broader Aboriginal and Torres Strait Islander population, particularly in light of updated evidence presented in the 2014 report of the US Surgeon General, which concludes that smoking increases the risk of developing type 2 diabetes in a clear dose–response manner.2

Our results also show a need to build knowledge that smoking causes low birthweight, which was either denied or not known by 18% of daily smokers, similar to previous findings.14,30 Messages that smoking causes lung cancer and heart disease and is dangerous to children have all featured on cigarette pack warning labels.31 Together with other sources of health information, such as mass media, news stories, local health promotion strategies and advice from health professionals, these are likely to have contributed to the high knowledge about these health effects among our Aboriginal and Torres Strait Islander participants.

Given health services are an important source of health information, it was surprising that knowledge was lower among smokers surveyed by sites with dedicated tobacco control resources. Though difficult to explain, this may be an indirect effect of the prioritisation of limited tobacco control resources to areas of greatest need, particularly as these resources included federally funded positions that had not long been established.9 Alternatively, it may suggest that information about the health effects of smoking is more effective when incorporated into established routine health service activities that include other areas of health and wellbeing.

Our findings suggest that gaps in knowledge are not responsible for the high prevalence of smoking or the social patterning of smoking among Aboriginal and Torres Strait Islander people. Contrary to the geographic and social patterning of smoking prevalence among Aboriginal and Torres Strait Islander people,7,32 we found that those from more remote and disadvantaged areas were more knowledgeable about the harmful effects of smoking and SHS. This is not to say that increasing knowledge is not important; prospective analyses from other ITC Project studies consistently show that knowledge, worry and risk beliefs contribute to motivation to quit.16,18,22,33 Though we have shown that knowledge is also related to interest in quitting among Aboriginal and Torres Strait Islander smokers, other factors are likely to be more important in influencing the success of quit attempts (and their translation to reduced prevalence), as found in other populations.17 For example, stress is commonly cited by Aboriginal and Torres Strait Islander smokers as a trigger for relapse,12,15,34,35 and it should be considered among other possible barriers including social normalisation of smoking, underlying social disadvantage, nicotine dependence and access to and uptake of services to support quitting.36

Among smokers, knowledge of SHS harms was associated with wanting to quit and attempts to quit, but knowing about direct, personal health consequences was not. Similarly, in an ITC Project survey in New Zealand, setting an example to children was more likely to be identified by Maori and Pacific peoples as a reason to quit, and was associated with SHS awareness and protective behaviour among smokers.37 Our findings are also consistent with qualitative research from the Northern Territory,15,24 in which Aboriginal participants expressed higher levels of concern for the health of others than for personal risk. Health is considered by many Aboriginal and Torres Strait Islander people to include the health of others.38 This may also explain why risk-minimising beliefs did not reduce interest in quitting, as predicted from research in the general population, despite being held at similar levels.21,22 It may be that these counterarguments are an ineffective shield to risks that include the health of others, and so have little or no effect on interest in quitting among Aboriginal and Torres Strait Islander people.

Our findings weaken the argument that risk-minimising beliefs explain why smoking persists in contexts where knowledge is high, and provide evidence that challenging these beliefs is unlikely to increase interest in quitting among Aboriginal and Torres Strait Islander people. Rather, health information may be interpreted with greater priority and relevance where negative health effects are framed in ways that include the health of others. This supports the approach used in the “Break the Chain” campaign, Australia’s first national Aboriginal and Torres Strait Islander antismoking campaign, launched in March 2011.39

Strengths and limitations

This is the first broadly representative survey of knowledge and health risk beliefs about smoking among Aboriginal and Torres Strait Islander peoples. The survey design made it feasible to interview a large number of people and to explore variation within our sample.

However, use of closed-ended questions may have led to overestimation of knowledge,40,41 which was assessed for a limited number of general health consequences of smoking. Knowledge may also have been overestimated if participants responded “yes” without fully scrutinising each question or because they did not want to appear uninformed. However, variation in the proportion of respondents who showed uncertainty in response to each item is evidence against this being systematic. Repeating the analyses with the “no” response as the dependent variable found the same general pattern of results (reversed). This increased our confidence in the validity of these outcomes, but did show that respondents from the most remote and disadvantaged areas were less likely to respond “don’t know”, consistent with biases to acquiesce or provide socially desirable responses in these areas. Some of the differences found, particularly area-level ones, may be due to social desirability biases, which are thought to be moderated by culture.42 Although face-to-face interviews can increase perceived pressure to provide socially acceptable responses, we attempted to reduce any such effects by engaging local interviewers, to minimise the social distance between the interviewer and participant.42

The questions used to assess health worry and risk minimisation showed good face validity, but have not been previously used to investigate these constructs with Aboriginal and Torres Strait Islander people. While these results paint a broad, representative picture of general health knowledge, concern and influence on quitting among Aboriginal and Torres Strait Islander people, more detailed assessments of knowledge may identify other gaps to target in future health information campaigns.

In conclusion, this national study found that lack of basic knowledge about the health consequences of smoking is not an important barrier to wanting and attempting to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages in ways that encompass the health of others is likely to contribute to goal setting and prioritisation of quitting.

1 Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander peoples*

Survey question and response	Daily smokers (n = 1392)	Non-daily smokers (n = 251)	Ex-smokers (n = 311)	Never-smokers (n = 568)

Knowledge of direct health effects of smoking
Does smoking cause lung cancer?
Yes	94% (1305)	96% (242)	96% (298)	99% (560)
No	2% (34)	1% (3)	2% (5)	1% (4)
Don’t know	3% (45)	2% (6)	2% (7)	1% (4)
Does smoking cause heart disease?
Yes	89% (1234)	92% (231)	92% (286)	93% (526)
No	4% (50)	2% (6)	4% (11)	2% (13)
Don’t know	7% (101)	6% (14)	4% (13)	5% (29)
Does smoking make diabetes worse?
Yes	68% (945)	78% (197)	71% (220)	77% (435)
No	7% (102)	6% (15)	5% (16)	5% (28)
Don’t know	24% (338)	16% (39)	24% (74)	18% (105)
Does smoking cause low birthweight?
Yes	82% (1131)	87% (218)	84% (261)	88% (499)
No	5% (75)	3% (7)	5% (15)	2% (9)
Don’t know	13% (179)	10% (25)	11% (33)	11% (60)
Correct response to all four questions on direct effects of smoking	59% (822)	72% (181)	61% (190)	71% (403)
Knowledge of health effects of second-hand smoke
Does smoking cause asthma in children from second-hand smoke?
Yes	91% (1265)	94% (235)	95% (293)	94% (535)
No	3% (38)	2% (6)	2% (7)	1% (6)
Don’t know	6% (82)	4% (10)	3% (10)	5% (27)
Cigarette smoke is dangerous to non-smokers
Agree or strongly agree	90% (1251)	95% (238)	95% (295)	96% (546)
Neutral or don’t know	7% (92)	3% (7)	2% (7)	2% (14)
Disagree or strongly disagree	3% (40)	2% (6)	2% (7)	1% (8)
Cigarette smoke is dangerous to children
Agree or strongly agree	95% (1317)	98% (245)	99% (306)	99% (560)
Neutral or don’t know	4% (52)	2% (4)	1% (2)	1% (6)
Disagree or strongly disagree	1% (14)	1% (2)	0 (1)	0 (2)
Correct response to all three questions on harms of second-hand smoke	85% (1173)	90% (227)	91% (282)	91% (518)
Health risk beliefs
Smoking is not very risky when you think about all the things that people do
Agree or strongly agree	44% (605)	50% (126)	—	—
Neutral or don’t know	18% (243)	16% (39)	—	—
Disagree or strongly disagree	39% (535)	34% (86)	—	—
How worried are you that smoking will damage your health in the future?
Very worried	36% (498)	27% (68)	—	—
A little or moderately worried	54% (735)	63% (156)	—	—
Not at all worried	10% (138)	10% (24)	—	—

* Results are based on the baseline sample (n = 2522) of the Talking About The Smokes project and are presented as % (frequency). Refused responses are excluded.

2 Association of knowledge and health risk beliefs with wanting and attempting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*

	Want to quit			Attempted to quit in the past year
Knowledge and health risk beliefs	% (frequency)†	Adjusted OR (95% CI)‡	P§	% (frequency)†	Adjusted OR (95% CI)‡	P§

Knowledge about direct effects of smoking
Fewer than all four questions correct	66% (395)	1.0	0.16	50% (312)	1.0	0.67
All four questions correct	72% (686)	1.21 (0.93–1.57)		49% (482)	0.95 (0.77–1.18)
Knowledge about harms of second-hand smoke
Fewer than all three questions correct	46% (101)	1.0	< 0.001	36% (83)		< 0.001
All three questions correct	74% (981)	3.26 (2.25–4.70)		52% (710)	1.89 (1.38–2.57)
Risk-minimising beliefs
Don’t know or disagree (neutral)	72% (622)	1.0	0.21	50% (440)	1.0	0.79
Agree	67% (461)	0.83 (0.62–1.11)		49% (353)	0.97 (0.78–1.21)
Health worry
Not at all or moderately worried	59% (576)	1.0	< 0.001	43% (450)	1.0	< 0.001
Very worried	90% (500)	6.17 (4.40–8.66)		60% (338)	2.14 (1.68–2.73)

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

Dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers

In 1988, the United States Surgeon General concluded that nicotine is the drug in tobacco that causes dependence on smoking.1 The nicotine that is delivered to the brain when smoking interacts with the habits and sensory stimuli associated with smoking to reinforce the behaviour.2 Genetic factors also influence the biological processes of nicotine delivery, metabolism and dependence.2

Clinicians and scientists have sought indicators to predict the success or failure of quit attempts, beyond indicators of motivation. The best such measure is the Heaviness of Smoking Index (HSI),3 or at least one of its two component items: cigarettes per day (CPD) and the time to first cigarette (TTFC) after waking.4,5 These two items are a subset of the six items in the Fagerström Test for Nicotine Dependence.6 There is also evidence that strong cravings (both before and after quitting) and shorter periods of abstinence on past attempts may independently predict failure of quit attempts.7–9 Identifying smokers who are most likely to have difficulty quitting is important in determining who might benefit from medications to assist cessation.

The age-standardised prevalence of smoking is 2.6 times higher among Aboriginal and Torres Strait Islander people as among other Australians.10 While both smoking prevalence and smoking intensity (based on self-reported CPD) are falling among the Aboriginal and Torres Strait Islander population, measures of dependence may differently predict which smokers will have the most difficulty quitting in this high-prevalence population where smoking is more normalised.10,11 Two small research reports have suggested that over-reliance on strategies that use stop-smoking medications may not be appropriate in this population, as nicotine dependence may be lower than in other populations.12,13 One of these studies found only low per capita consumption of cigarettes in remote Aboriginal communities,12 and the other found that only a small proportion of a sample of pregnant Aboriginal and Torres Strait Islander women who smoked were highly dependent.13

Here, we use a large national study of Aboriginal and Torres Strait Islander smokers to examine different indicators of dependence in this population and their association with sustained quit attempts, and to make comparisons with a national sample of Australian smokers.

Methods

The Talking About The Smokes (TATS) project surveyed 1392 Aboriginal and Torres Strait Islander daily smokers using a quota sampling design in the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait, and has been described elsewhere.14,15 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or ex-smokers who had quit ≤ 12 months before, and 25 non-smokers, with equal numbers of women and men and of those aged 18–34 and ≥ 35 years. In four major-city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged less than 18 years, not usual residents of the area, staff of the ACCHS, or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. The baseline sample closely matched the national distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.14

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.16 TATS project results were compared with those for 1010 daily smokers surveyed in Wave 8.5 of the Australian ITC Project between September 2011 and February 2012. That survey was completed by random digit telephone dialling or on the internet, and included smokers contacted for the first time and those who were recontacted after completing surveys in previous waves.

We asked questions about daily smokers’ usual smoking behaviour and variations in tobacco consumption, how easy it would be to not smoke, difficulties during their most recent quit attempt (eg, strong cravings, being around others who smoke), the duration of their longest quit attempt (to assess if any attempt had been sustained for at least 1 month) and sociodemographic factors. The questions are described in detail in Appendix 1.

The HSI was coded 0 to 6 based on the sum of the responses to the two questions about CPD and TTFC. These items were each coded as 0 (0–10 CPD; TTFC, ≥ 61 min), 1 (11–20 CPD; TTFC, 31–60 min), 2 (21–30 CPD; TTFC, 6–30 min) or 3 (≥ 31 CPD; TTFC, ≤ 5 min).3 We categorised HSI as low (0–1), moderate (2–3) or high (4–6).17,18 We also assessed the three criteria for dependence given in the Royal Australian College of General Practitioners (RACGP) cessation guidelines: TTFC ≤ 30 min, > 10 CPD, and withdrawal symptoms on previous quit attempts (defined in our sample as strong cravings during the most recent quit attempt).2

Statistical analyses

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

Within the TATS project sample, we assessed the association between sociodemographic variables and HSI using χ2 tests adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands.19 We assessed the association between indicators of dependence and sustained quit attempts using simple logistic regression, with confidence intervals adjusted for the sampling design and P values calculated for each variable using adjusted Wald tests.

Reported percentages and frequencies exclude those refusing to answer, answering “don’t know”, or for whom the question was not applicable (eg, questions about the most recent quit attempt excluded those who had not made an attempt in the past 5 years). Less than 2% of daily smokers answered “don’t know” or refused to answer each of the questions analysed here, except that 18 smokers (2.0%) answered “don’t know” to the question about difficulty in saying no when offered a cigarette during their most recent quit attempt, and 32 (2.3%) refused to answer the question about being unable to afford to buy cigarettes.

Results

There was little difference in the mean HSI scores for daily smokers in the TATS project compared with those in the Australian ITC Project (2.62 v 2.64; 95% CI, 2.45–2.83), but the TATS sample had fewer low and high scores and more moderate scores (Box 1). A higher proportion of smokers in the TATS project smoked 10 or fewer cigarettes per day (40% v 33.4%), but more also smoked their first cigarette within 30 minutes of waking (75% v 64.6%; 95% CI, 58.8%–70.0%). Lower proportions of Aboriginal and Torres Strait Islander smokers reported having strong urges to smoke at least several times a day (51% v 60.7%) or that it would be very hard to quit (39% v 47.9%).

Within the TATS sample, older smokers were more likely to have higher HSI scores, as were smokers who were not in the labour force, those with less education, those from both the most and least disadvantaged areas, and Aboriginal smokers compared with Torres Strait Islander smokers (Box 2).

Box 3 presents the results for questions that were only asked in the TATS project. Nearly half the smokers (47%) reported finding it very or extremely hard to go without smoking for a whole day, and most reported experiencing difficulties during their most recent quit attempt. A quarter (24%) of daily smokers had all three of the RACGP indicators of dependence.

Among the 61% of smokers in the TATS sample (833/1371) who had made a quit attempt in the past 5 years, all the indicators of dependence, except CPD and strong urges, were associated with being less likely to have made a sustained quit attempt of at least 1 month (Box 4). The indicators with the strongest negative associations with making a sustained quit attempt were the smokers’ assessments of how hard it would be to quit and their difficulties during the most recent quit attempt. Although the HSI and the RACGP criteria of dependence were negatively predictive of making a sustained quit attempt, CPD — one of their component measures — was not.

Nearly half the daily smokers in the TATS sample (45%, 606/1354) reported being unable to buy cigarettes for at least a few days in each fortnight before pay day, and 23% (314/1354) less often, while for 32% (435/1354) this was never a problem. When smokers were unable to buy them, 37% (342/916) reported they were often or very often given cigarettes, and 50% (460/916) were sometimes given them. As a result, 27% (245/911) said they smoked the same amount as usual when unable to buy cigarettes, while 50% (456/911) smoked a bit less and only 23% (210/911) smoked a lot less or not at all.

Compared with Australian smokers in the ITC Project, fewer Aboriginal and Torres Strait Islander smokers in the TATS project reported that the amount they smoked varied from day to day (42% [580/1392] v 58.5% [95% CI, 53.1%–63.7%]), but more reported that spending money on cigarettes left them with insufficient money for food or other essentials (23% [321/1378] v 12.9% [95% CI, 8.7%–18.6%]).

The Aboriginal and Torres Strait Islander smokers whose smoking led to insufficient money for essentials were less likely to have made sustained attempts to quit (odds ratio [OR], 0.70; 95% CI, 0.37–0.71; P < 0.001). Smokers who were never unable to afford cigarettes were less likely to have made a sustained quit attempt than those who were sometimes unable to buy them (OR, 0.51; 95% CI, 0.37–0.71; P < 0.001). Those who said they smoked about the same as usual when they were unable to buy cigarettes were also less likely to have made a sustained quit attempt, compared with those who at such times smoked a lot less or not at all (OR, 0.61; 95% CI, 0.41–0.91; P = 0.01).

Discussion

We found mixed relationships between indicators for dependence and sustained quit attempts in our sample of Aboriginal and Torres Strait Islander smokers. Based on CPD, frequency of strong urges to smoke and perceptions of how hard it would be to quit, dependence in this population appeared lower than among all Australian smokers. In contrast, our sample had a shorter TTFC. Nevertheless, the associations we found between dependence, as measured by the HSI, and being older and socially disadvantaged were similar to those in previous cross-sectional Australian ITC Project research.20

Previous research suggests TTFC is a more useful measure of dependence and a better predictor of successful quitting than CPD, although both are predictive and may contribute independently.4,5,21,22 Consistent with this, we found that longer TTFC was associated with having made a sustained quit attempt, while CPD was not. However, we also found no association for the frequency of strong urges while still smoking, which has been shown to be associated with successful quitting in longitudinal research, performing better than the Fagerström Test for Nicotine Dependence or its components, HSI, TTFC or CPD.7,8 These findings question the utility of existing indicators of dependence to predict successful quitting in Aboriginal and Torres Strait Islander smokers.

Aboriginal and Torres Strait Islander smokers’ perceptions of greater ease in quitting (quitting self-efficacy) may be falsely optimistic, perhaps reflecting less experience of unsuccessful quit attempts.23 In 2012–2013, only 37% of Aboriginal and Torres Strait Islander adults who had ever smoked had successfully quit, compared with 63% of other Australians.10 Some of the cross-sectional association we found between quitting self-efficacy and sustained quit attempts is likely to be in the reverse direction, with those who have not been able to sustain quit attempts understandably reporting that quitting will be harder. However, in other longitudinal research of the ITC Project, quitting self-efficacy has been associated with preventing relapses, both before and after a month.7 Nevertheless, we can take advantage of this optimism to encourage quit attempts.

Most Aboriginal and Torres Strait Islander smokers reported withdrawal symptoms (cravings) and situational difficulties during their most recent quit attempt, which have been described in more detail in previous qualitative research.24 It is notable that questions about the most recent quit attempt were consistently stronger predictors of being unable to sustain quit attempts than were traditional measures of dependence based on typical daily smoking patterns. Our results are consistent with more detailed recent research in other settings, which suggested that the components of the HSI are only predictive of early relapses in the first weeks of a quit attempt, whereas cravings and situational cues (such as the number of close friends who smoke) are important after 1 month.7,25

Current clinical guidelines recommend that clinicians ask smokers not only about CPD and TTFC, but also about their past unsuccessful quit attempts.26,27 Beyond emphasising the utility of the existing question about difficulties experienced during past attempts, we recommend waiting for further research on how the different measures prospectively predict quitting success before suggesting changes to the guidelines for Aboriginal and Torres Strait Islander smokers.

It is possible that estimates of CPD might be less accurate among Aboriginal and Torres Strait Islander smokers, where the relationship between purchase and consumption is more complicated because sharing and being unable to buy cigarettes are common. Two small studies of Aboriginal and Torres Strait Islander people showed that self-reported CPD is associated with urinary cotinine levels, but did not discuss whether the association was similar to that in other populations.28,29 However, we found that Aboriginal and Torres Strait Islander smokers were less likely than all Australian smokers to report variation in the number of cigarettes smoked each day, so it is difficult to suggest that such day-to-day variations are the reason for CPD being less useful in this setting. Those who managed to maintain usual consumption levels when they were unable to buy cigarettes were less likely to have sustained a quit attempt than those who smoked less at these times. Sharing of cigarettes therefore seems to increase in response to the inability to buy cigarettes among more dependent smokers, as has been reported elsewhere in response to pay cycles and the increased cost of cigarettes after tobacco excise rises.24,30

Strengths and limitations

The main strength of our study is its large national sample of Aboriginal and Torres Strait Islander smokers, providing detailed information about dependence directly from a population with a high prevalence of smoking. However, it is a non-random, albeit broadly representative, sample and caution is needed in making comparisons with the Australian ITC Project sample.

The cross-sectional associations we found warrant confirmation from future longitudinal analyses. There may have been some reverse causation, with past experiences of sustaining or not sustaining quit attempts influencing answers to the questions about dependence. Further, sustained attempts may have occurred years earlier, and the smokers’ dependence may have since changed. The use of past sustained quit attempts as an outcome necessarily meant excluding those who had not made any attempts. Predicting future quitting in this subgroup will be important but cannot include measures based on non-existent past attempts.

Our self-reported data are probably limited by incomplete recall of past quit attempts, and both forgetting and misremembering of symptoms. The effect of most of these biases will be to weaken reported associations, leading to greater confidence in the significant associations but requiring caution in the implications of findings of no association. For example, the lack of association of strong urges to smoke with sustained quitting found here, in contrast to other research, requires further exploration.8 More Aboriginal smokers than other Australian smokers use roll-your-own cigarettes, which may have caused greater misclassification bias of estimates of CPD.31 Future longitudinal analyses of the predictive association of these dependence measures with relapses and successful quitting should also control for the moderating effect of stop-smoking medication, which we were not able to do.25

1 Comparison of indicators of nicotine dependence among Aboriginal and Torres Strait Islander daily smokers and those in the Australian population*

Indicator of dependence

Talking About The Smokes project, % (frequency)†

Australian ITC Project,
% (95% CI)‡

Cigarettes per day

1–10

40% (547)

33.4% (27.9%–39.3%)

11–20

39% (528)

42.2% (36.8%–47.7%)

21–30

18% (242)

18.5% (14.7%–22.9%)

≥ 31

4% (54)

6.0% (3.7%–9.6%)

Time to first cigarette

More than 60 minutes

9% (125)

16.1% (11.9%–21.3%)

31–60 minutes

16% (220)

19.4% (15.3%–24.2%)

6–30 minutes

64% (884)

46.7% (41.2%–52.3%)

5 minutes or less

11% (145)

17.9% (13.6%–23.2%)

Heaviness of Smoking Index (HSI) score

Low (0–1)

17% (234)

24.5% (19.5%–30.3%)

Moderate (2–3)

59% (796)

44.6% (39.2%–50.1%)

Heavy (4–6)

24% (328)

30.9% (25.8%–36.5%)

How often do you get strong urges to smoke?

Never or less than daily

21% (291)

12.4% (9.0%–16.9%)

Daily

27% (375)

26.9% (21.9%–32.5%)

Several times a day or more often

51% (706)

60.7% (54.9%–66.2%)

How easy or hard would it be for you to quit?

Very or somewhat easy

17% (234)

10.4% (6.9%–15.4%)

Neither easy nor hard

11% (156)

7.9% (5.0%–12.2%)

A little bit hard

32% (439)

33.7% (28.8%–39.0%)

Very hard

39% (537)

47.9% (42.3%–53.6%)

ITC Project = International Tobacco Control Policy Evaluation Project. * Percentages and frequencies exclude refused responses and “don’t know” responses. † Results are for Aboriginal and Torres Strait Islander daily smokers (n = 1392) in the baseline sample of the Talking About The Smokes project (April 2012 – October 2013). ‡ Results are for daily smokers (n = 1010) in the Australian population from Wave 8.5 of the Australian ITC Project (September 2011 – February 2012) and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey.

2 Heaviness of Smoking Index among Aboriginal and Torres Strait Islander daily smokers, by sociodemographic factors (n = 1392)*

	Heaviness of Smoking Index score
Characteristic	Low, % (frequency)	Moderate, % (frequency)	High, % (frequency)	P†

Total daily smokers	17% (234)	59% (796)	24% (328)
Age (years)				< 0.001
18–24	22% (60)	68% (187)	11% (29)
25–34	21% (76)	57% (209)	23% (84)
35–44	14% (45)	58% (186)	28% (92)
45–54	16% (37)	56% (132)	28% (67)
≥ 55	10% (16)	53% (82)	36% (56)
Sex				0.12
Female	19% (134)	59% (417)	22% (153)
Male	15% (100)	58% (379)	27% (175)
Indigenous status				0.027
Aboriginal	16% (195)	59% (717)	25% (297)
Torres Strait Islander or both	26% (39)	53% (79)	21% (31)
Labour force status				< 0.001
Employed	21% (101)	58% (274)	21% (97)
Unemployed	18% (82)	63% (293)	19% (89)
Not in labour force	12% (51)	54% (227)	34% (142)
Highest education attained				0.036
Less than Year 12	14% (101)	59% (411)	27% (188)
Finished Year 12	19% (68)	58% (204)	23% (80)
Post-school qualification	22% (63)	59% (172)	20% (57)
Treated unfairly because Indigenous in past year				0.72
Never	18% (106)	57% (335)	25% (145)
At least some of the time	17% (124)	59% (439)	24% (176)
Remoteness				0.34
Major cities	15% (52)	60% (214)	25% (88)
Inner and outer regional	19% (137)	59% (420)	22% (158)
Remote and very remote	16% (45)	56% (162)	28% (82)
Area-level disadvantage				0.027
1st quintile (most disadvantaged)	16% (83)	57% (290)	27% (137)
2nd and 3rd quintiles	21% (121)	59% (342)	21% (121)
4th and 5th quintiles	11% (30)	62% (164)	27% (70)

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † P values were calculated using the χ2 test adjusted for sampling design.

3 Other indicators of nicotine dependence and difficulties during the most recent quit attempt among Aboriginal and Torres Strait Islander daily smokers

Indicator of dependence	Daily smokers, % (frequency)*

All daily smokers (n)	1392
RACGP criteria for dependence†
None	12% (162)
One	24% (334)
Two	41% (564)
All three	24% (327)
How hard is it to go without smoking for a whole day?
Not at all or somewhat hard	47% (654)
Very or extremely hard	47% (657)
Not sure or never tried	6% (79)
If tried to quit in the past 5 years (n)	884
During last quit attempt
Had strong cravings	70% (591)
Hard to be around smokers	72% (621)
Hard to say no when offered a smoke	67% (572)
Missed the time out you get when having a smoke	51% (430)

RACGP = Royal Australian College of General Practitioners. * Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Time to first cigarette ≤ 30 min, > 10 cigarettes per day, and withdrawal symptoms on previous quit attempts (strong cravings during most recent quit attempt).

4 Association of indicators of dependence with sustaining a quit attempt for at least 1 month in a national sample of Aboriginal and Torres Strait Islander daily smokers*

Indicator of dependence	Sustained quit attempt, % (frequency)†	Odds ratio (95% CI)‡	P§

Total	47% (388)
Heaviness of Smoking Index score			0.046
Low (0–1)	50% (71)	1.0
Moderate (2–3)	48% (238)	0.91 (0.66–1.26)
Heavy (4–6)	38% (68)	0.60 (0.39–0.91)
RACGP criteria for dependence			0.001
None	54% (38)	1.0
One	57% (92)	1.12 (0.60–2.09)
Two	47% (133)	0.73 (0.43–1.24)
All three	39% (124)	0.55 (0.33–0.90)
Cigarettes per day			0.19
1–10	47% (153)	1.0
11–20	48% (163)	1.02 (0.75–1.38)
21–30	45% (57)	0.89 (0.58–1.37)
≥ 31	27% (9)	0.42 (0.18–0.94)
Time to first cigarette			0.024
More than 60 minutes	53% (43)	1.0
31–60 minutes	55% (73)	1.08 (0.57–2.03)
6–30 minutes	45% (235)	0.72 (0.45–1.13)
5 minutes or less	36% (31)	0.51 (0.27–0.94)
How often do you get strong urges to smoke?			0.49
Never or less than daily	49% (90)	1.0
Daily	47% (109)	0.91 (0.61–1.38)
Several times a day or more often	45% (184)	0.82 (0.58–1.17)
How hard is it to go without smoking for a whole day?			0.01
Not at all or somewhat hard	51% (219)	1.0
Very or extremely hard	42% (159)	0.69 (0.52–0.92)
Not sure or never tried	33% (9)	0.47 (0.22–1.05)
How easy or hard would it be for you to quit?			< 0.001
Very or somewhat easy	61% (94)	1.0
Neither easy nor hard	53% (46)	0.72 (0.42–1.25)
A little bit hard	46% (125)	0.53 (0.36–0.78)
Very hard	38% (120)	0.39 (0.27–0.56)
During most recent quit attempt
Did you get strong cravings?			< 0.001
No	59% (149)	1.0
Yes	42% (236)	0.49 (0.37–0.66)
Was it hard to be around smokers?			< 0.001
No	59% (133)	1.0
Yes	42% (252)	0.51 (0.38–0.69)
Was it hard to say no when offered a smoke?			< 0.001
No	58% (154)	1.0
Yes	41% (225)	0.50 (0.35–0.70)
Did you miss the time out you get when having a smoke?			0.03
No	51% (197)	1.0
Yes	44% (179)	0.74 (0.56–0.98)

RACGP = Royal Australian College of General Practitioners. * Results are based on daily smokers in the baseline sample of the Talking About The Smokes project who had made at least one quit attempt in the past 5 years (n = 833). † Percentages and frequencies exclude those answering “don’t know” or refusing to answer. ‡ Odds ratios calculated using simple logistic regression adjusted for the sampling design. § P values for the entire variable, using adjusted Wald tests.

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Somaliland has made impressive gains in strengthening its health services, but substantial challenges remain for the unrecognised nation. Sharmila Devi reports from the capital Hargeisa.

[Correspondence] Frailty in sub-Saharan Africa

Most high-income countries are called to urgently adapt their health-care systems to meet the new challenges arising from their ageing populations. Models of health-care services aimed at preventing age-related disabling disorders (including the design of screening and assessment instruments) are largely from high-income countries. Little consideration has been given to ageing and its resulting effects in low-income and middle-income regions. This absence of interest for the effects of ageing in low-income regions is worrying because these areas are not only highly populated (especially in absolute numbers), but also have the same demographic trends that characterise high-income countries.

Doctors get their own dedicated national health service

All doctors and medical students will have access to a health service dedicated to meeting their needs no matter where they live and work following a landmark agreement between the AMA and the Medical Board of Australia.

The Medical Board has contracted the AMA, through its wholly-owned subsidiary Doctors Health Services Pty Ltd (DHS), to ensure specific health services for medical practitioners and students are accessible nationwide.

The deal is the culmination of years of work to provide doctors with nationally consistent health services that cater specifically for their needs amid concerns that often practitioners have gone untreated for significant health problems that not only harm them but may place their patients at risk.

The Medical Board announced last year that it would fully fund a national health program for doctors and medical students, and Chair Dr Joanna Flynn said the contract with the AMA was an important milestone in achieving that goal.

“The Board is committed to supporting the wellbeing of all doctors and medical students in Australia,” Dr Flynn said. “Creating health services that are accessible and fair to everyone – and are targeted to meet doctors’ needs – is a really important contribution we are proud to make.”

The announcement of a dedicated national health program for medical practitioners has come just weeks after the medical community was rocked by the sudden death of four young doctors in Victoria. And a 2013 beyondblue report showed that psychological distress, burnout and suicide were disturbingly common among doctors and medical students.

There are long-standing concerns that many doctors with mental health problems, issues of substance abuse and physical ailments have been reluctant to seek help for fear it will harm their career.

There has been a call to rigorously address the reasons some doctors find it hard to seek and obtain help, including the culture of the profession, the work environment, the training culture, and mandatory reporting.

While there has been a gradual increase in the number of health services specifically for doctors, AMA Vice President Dr Stephen Parnis recently said current arrangements were inadequate, and the AMA had for a long time strongly advocated for a national model to support the work of the services that make up the Australasian Doctors’ Health Network.

AMA President Associate Professor Brian Owler said the establishment of Doctors Health Services would deliver on that goal.

While the Medical Board will fund the program, A/Professor Owler emphasised that it would play no role in its operation or the delivery of services.

“Critically, the services will remain at arm’s length from the Medical Board to ensure that doctors and medical students trust these services and use them at an early stage in their illness,” he said.

Existing doctor health services will be invited to express interest in continuing as a provider. Under the new contract arrangements, they will be required to provide confidential triage and referral services, health advice and education, training for practitioners to treat other doctors and facilitation of support groups.

DHS will have a five-member Board including an AMA representative, a doctor in training representative and a medical practitioners with experience in providing doctor health services. The Board will be supported by an expert advisory committee made up of service providers, medical students, doctors in training and AMA representatives.

Adrian Rollins

Managing the AMA List

The AMA List of Medical Services and Fees (the List) plays a significant role in lobbying Government on what it costs to provide medical care. It also provides an important and valuable tool for doctors to assist us with our fee setting and indexation.

Historically, items in the List have broadly aligned with items on the Medicare Benefits Schedule (MBS) by applying Government decisions for funding of medical services as amendments and additions to the List.

But the Government’s increasing tendency in recent years to look for ways to curb spending on health has changed the nature of its funding decisions. Typically, Government changes are no longer by way of simple amendments and additions, but now involve further restrictions and limits on how items may be used.

Consequently, there has been a need to develop a new approach to managing the AMA List and how it should align with the MBS in the future.

The first significant deviation from the Government’s traditional MBS approach was in 2007 when it introduced a specific age-limited item for the Healthy Kids check on the Medicare schedule.

Since that point, governments of both persuasions have pursued budget and health reform agendas that have severely limited the MBS by not allowing or significantly delaying many clinically appropriate procedures from being included on the Schedule.

A clear example was sacral nerve stimulation for urinary incontinence, which was recommended for MBS funding in 2008 but was not introduced on the Schedule until almost 18 months later.

Governments have also withdrawn MBS funding for clinically relevant services by justifying the measure as a minor procedure that should form part of a standard consultation. We saw this with the removal of joint injections.

In the years since, we have also seen governments include brakes on health spending by imposing further restrictions to item descriptors and placing additional caveats on how services can be delivered. Typically, such restrictions have not been specific recommendations of the Medical Services Advisory Committee, but have been introduced by the Department of Health to limit health expenditure.

As time has passed, it has become more difficult to maintain alignment of the AMA List with the MBS.

To maintain the List as a tool to demonstrate the costs of medical care, and to assist us in our fee setting, there is a need to set key principles for managing the List, rather than just automatically accepting Government policies.

This has included identifying circumstances where the List should no longer automatically align with the MBS because:

the Government either delays or withdraws Medicare funding for clinically relevant medical services on the MBS;
the medical specialty groups propose changes to MBS items to reflect current clinical practice, and the Government defers implementation of the changes;
the service does not reflect appropriate clinical practice or is not listed on the MBS but is considered by the AMA as being a clinically relevant service; or
the MBS service:
- is required to be performed according to specified clinical guidelines;
- precludes the billing of a consultation on the same day;
- specifies the training, qualifications and/or competencies of the treating medical practitioner; or
- is restricted to particular requirements of other Government programs, such as the Pharmaceutical Benefits Schedule.

In this regard, the AMA welcomes the Government’s recent announcement of the MBS Review Taskforce and Primary Health Care Advisory Group to consider how services can be aligned with contemporary clinical evidence and improve health outcomes for patients.

We are also pleased that both groups will be led by eminent and highly-regarded clinicians, and will be based on frontline medical evidence and experience. We hope that a positive outcome of these reviews will enable better alignment of the MBS and the AMA List.