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

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

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

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

Visits to general practitioners and tests associated with communicable disease investigations

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

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

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

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

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

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

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

Methods

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

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

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

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

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

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

Statistical analyses

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

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

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

Results

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

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

Strengths and limitations

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

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

Ever used NRT or SSMs

Used NRT or SSMs in the past year

Smoking characteristic

% (frequency)*

Odds ratio (95% CI)†

P‡

% (frequency)*

Odds ratio (95% CI)†

P‡

Smokers and recent ex-smokers (n = 1721)

Smoking status

Daily smokers

37% (515)

1.0

< 0.001

23% (318)

1.0

0.001

Non-daily smokers

17% (43)

0.35 (0.24–0.51)

12% (30)

0.46 (0.29–0.73)

Recent ex-smokers§

36% (28)

0.94 (0.57–1.55)

32% (25)

1.59 (0.95–2.66)

Daily smokers only (n = 1369)

Heaviness of Smoking Index score

Low (0–1)

30% (69)

1.0

< 0.001

18% (42)

1.0

0.06

Moderate (2–3)

36% (284)

1.34 (1.00–1.81)

23% (184)

1.39 (0.92–2.08)

Heavy (4–6)

45% (148)

1.98 (1.42–2.76)

27% (86)

1.65 (1.08–2.51)

RACGP criteria for dependence¶

None

24% (38)

1.0

< 0.001

13% (20)

1.0

< 0.001

One

27% (91)

1.23 (0.78–1.92)

17% (55)

1.38 (0.84–2.28)

Two

35% (192)

1.71 (1.12–2.61)

21% (118)

1.89 (1.11–3.22)

All three

59% (193)

4.66 (2.99–7.27)

39% (125)

4.39 (2.56–7.51)

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

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

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

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

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

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

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

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

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

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

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

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

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

Inappropriate pathology ordering and pathology stewardship

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

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

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

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

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

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

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

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

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

Methods

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

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

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

Statistical analyses

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

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

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

Results

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

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

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

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

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

Discussion

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

Strengths and limitations

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

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

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

Comparisons with other studies

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

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

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

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

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

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

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

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

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

Australian ITC Project, % (95% CI)†

TATS project, % (frequency)‡

Seen a health professional

68.1% (64.8%–71.1%)

76% (1047)

Of those seen

Asked if he/she smokes§

—

93% (968)

Advised to quit

56.2% (52.3%–59.9%)

75% (782)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methods

Survey design and participants

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

Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, took 30–60 minutes to complete. A single survey of health service activities was also completed for each project site.

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

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

[World Report] Slowly and steadily, Somaliland builds its health system

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.