Energy drinks deliver deadly jolt

Young people turning to heavily-caffeinated energy drinks to fuel themselves for partying, sport or just to get through the day are putting themselves at heightened risk of heart attacks and chronic heart problems.

In a finding that suggests the marketing and consumption of so-called energy drinks should be much more tightly regulated, a detailed American study of their use has found they are associated with “adverse cardiovascular events”, including sudden and deadly heart attacks, ruptured arteries, heart arrhythmia, tachycardia and elevated blood pressure, particularly among adolescents and young adults.

“By unleashing the new ‘beast’ of energy drinks, we have now seen significant morbidity and mortality in susceptible patients,” the study’s authors said. “Young consumers are at a particularly high risk of complications due to hazardous consumption patterns, including frequent and heavy use.”

The study, Cardiovascular complications of energy drinks, published in the latest edition of the journal Beverages, documented numerous cases where people died or suffered serious cardiovascular problems after consuming energy drinks.

These include a 28-year-old man who collapsed while playing basketball after drinking three cans of energy drink five hours before the match. He was rushed to hospital suffering ventricular tachycardia and died three days later.

In another case, a 25-year-old woman with a pre-existing heart valve problem died from intractable ventricular fibrillation after drinking a 55 millilitre bottle of Race 2005 Energy Blast with Guarana and Ginseng. Subsequent tests found the drink contained caffeine at a concentration of 10 grams a litre – more than 60 times that in cola drinks – and the caffeine in the woman’s bloodstream was concentrated at 19 milligrams a litre, around double the level found in regular coffee drinkers.

The drinks have also been associated with potentially fatal spasms of coronary arteries. One case involved a man, 28, who drank between seven and eight cans of energy drink over a seven-hour period before and during motocross racing. Soon after he stopped he suffered a cardiac arrest, and was found to have had a coronary artery vasospasm doctors believe was precipitated by high levels of caffeine and taurine in his blood.

In addition to heart attacks and arterial spasms, energy drinks have also been associated with surges in blood pressure that can lead to rupture of arteries, and with the impairment blood vessel linings.

The authors said that while some of the cases involved people with pre-existing and underlying cardiac condition, many others did not. They reported the results of a review of 17 cases where people suffered heart attacks or other cardiac “events” after consuming energy drinks and found almost 90 per cent were younger than 30 years of age, and the majority did not have a cardiac abnormality.

While energy drinks advertise high concentrations of caffeine – around 80 milligrams in cans of Red Bull, Monster and Rockstar, and more than 200 milligrams in a 60 millilitre can of 5-Hour Energy compared with around 35 milligrams in a can of cola – researchers said other common ingredients, particularly taurine, which can interfere with the regulation of the cardiovascular system, could also have potentially severe consequences.

The researchers admitted that “confounding variables”, such as strenuous exercise, genetic predispositions and the simultaneous use of alcohol or recreational drugs meant that many deaths could not be attributed to energy drinks alone.

But they said it was clear that consuming energy drinks was associated with “cardiovascular events including death”, and urged much greater attention be paid to their use.

The US Food and Drug Administration reported 18 deaths associated with energy drinks between 2004 and 2012, and the researchers said that because the FDA reporting system typically captured between 1 and 10 per cent of actual adverse events, it was likely there were at least 180 deaths associated with energy drinks during that period.

Given the widespread consumption of energy drinks – Australia’s Food Regulation Standing Committee found that sales of energy drinks in Australia and New Zealand jumped from 34.5 million litres in 2001 to 155.6 million litres in 2010 – the study’s authors have called for greater awareness of the danger they present, particularly for young people, who are typically the biggest consumers.

“Children, young adults and their parents should be aware of the potential hazards of energy drinks,” the authors said. “Physicians should routinely inquire about energy drink consumption in relevant cases, and vulnerable consumers such as young persons should be advised against heavy consumption, especially with concomitant alcohol or drug ingestion.”

The researchers said there was no rigorous scientific evidence that energy drinks boosted energy or improved physical or cognitive performance, and there needed to be public education campaigns to highlight the hazards and dispel the myths about their benefits.

They called for eventual limits on the caffeine content of energy drinks and restrictions on their sale to young people, echoing calls from the AMA and the Country Women’s Association.

The AMA has for several years raised concerns about the health effects of energy drinks and their heavy consumption among young people, including children.

In 2013, the-then AMA President Dr Steve Hambleton demanded that the caffeine content of energy drinks be reduced, or their sale restricted to adults, following evidence linking them to serious effects in young people, including tachycardia and agitation.

In 2009, the death of a young woman was linked to caffeine from energy drinks, and a study published in the Medical Journal of Australia found 297 calls relating to caffeinated energy drinks were made to the NSW Poisons Information Centre between 2004 and 2010, 128 of which resulted in hospitalisation.

Two years ago the Country Women’s Association of New South Wales submitted a petition with 13,600 signatures to Federal Parliament calling for a ban on energy drink sales to everyone younger than 18 years.

Both the AMA and the CWA have highlighted inconsistencies in food standards that limit the amount of caffeine in soft drinks to a maximum of 145 milligrams per kilogram, but impose no similar limit on energy drinks.

Adrian Rollins

Image by Au Kirk on Flickr, used under Creative Commons licence

Curb the drinks to cut the violence

Australian of the Year Rosie Batty has backed calls for a crackdown on sales of alcohol, including an end to 24-hour trading and a buyback of liquor licenses, as part of efforts to stamp out family violence.

Echoing the AMA’s call last year for governments nationwide to take strong action to curb alcohol-related violence, Ms Batty has urged national leaders including Prime Minister Tony Abbott and Opposition leader Bill Shorten to adopt a set of proposals developed by the Foundation for Alcohol Research and Education (FARE) to reduce the saturation of alcohol in the community.

“There is not, and can never be, an acceptable level of family violence,” Ms Batty said. “Prevention must be our ultimate goal, and we must do everything in our power to stop it.”

Ms Batty’s plea has underlined the outcomes of the National Alcohol Summit organised by the AMA last October that called for a consistent national approach to the supply and availability of alcohol, including statutory regulation of alcohol marketing and a review of taxation and pricing arrangements.

AMA President Professor Brian Owler, who convened and led the Summit, said at the time that alcohol misuse was one of the country’s major health issues, with estimates that the damage it caused through violence, traffic accidents, domestic assaults, poor health, absenteeism and premature death, cost the community up to $36 billion a year.

“Alcohol-related harm pervades society. It is a problem that deserves a nationally consistent response and strategy,” Professor Owler said.

In recognition of the fact that often family doctors are the first port of call for victims of domestic violence, the AMA, in conjunction with the Law Council of Australia, last month released a toolkit providing guidance and resources for GPs in helping patients who have been attacked by their partners.

The Supporting parents experiencing family violence – a resource for medical practitioners toolkit can be downloaded at: article/ama-family-violence-resource

The plan to prevent alcohol-related family violence developed by FARE, launched by Ms Batty on 17 June, calls for those applying for liquor licenses to be subject to more stringent approval process, a restriction on trading hours, a liquor licensing freeze or buybacks in saturated areas, an end to 24 hour licences and an extra levy on alcohol to help pay for the costs incurred by governments in responding to family violence.

FARE said alcohol was a factor in 65 per cent of family violence incidents reported to police and almost half of child abuse cases. In addition, more than a third of those who murdered their partner had been drinking prior to the attack.

Chief Executive Michael Thorn said a tough problem called for tough solutions.

“Alcohol’s involvement in family violence is undeniable,” Mr Thorn said. “Governments must acknowledge the vast research and the irrefutable evidence that clearly links the availability of alcohol with family violence, and act accordingly. In practice, that means putting public interests ahead of the alcohol industry and being prepared to say no to liquor licence applications that put people at greater risk of harm.”

The FARE plan echoes the recommendations of last year’s AMA Summit in emphasising measures aimed at preventing alcohol-related harm while simultaneously urging ongoing funding for vital alcohol support and treatment services.

Professor Owler said that although individuals and communities had a role to play, governments – particularly the Commonwealth – needed to be far more active in tackling the issue.

“Too many times we hear that it’s all about personal responsibility. It’s rubbish,” Professor Owler said. “Personal responsibility is important, but we can’t rely on the personal choices of others for our own safety and health. Governments can influence behaviour through deterrents but, most importantly and more effectively, through shaping individual and societal attitudes to alcohol.”

For more information on the AMA National Alcohol Summit, visit: ausmed/end-cheap-grog-and-saturation-marketing-alcohol-summit-tells-govt

The National Alcohol Summit communique can be viewed at: media/ama-national-alcohol-summit-communique

Adrian Rollins

Disability support services: services provided under the National Disability Agreement 2013–14

In 2013–14, an estimated 321,531 people used disability support services under the National Disability Agreement (NDA), including 4,200 who transitioned to the National Disability Insurance Scheme (NDIS) during the year. Over half (55%) of all NDA service users had an intellectual or learning disability and many needed at least some assistance in one or more of the three broad life areas—activities of daily living (68%), activities of independent living (82%), and activities of work, education and community living (86%).

No crisis, but change is needed: Ley

Health system funding is not in crisis but there needs to be an overhaul of the way the Federal Government pays for GP and hospital services, Health Minister Sussan Ley told the AMA National Conference.

Setting out markers for the future direction of Government health policy, Ms Ley put doctors and state governments on notice that there will be changes to how the Commonwealth funds health care.

But, in a marked change of tone from her predecessor Peter Dutton, the Minister dropped warnings that health spending was unaffordable and embraced a collaborative approach to change.

“The Government is not claiming that we are in a health funding crisis,” Ms Ley said, though she added that, “we are saying that we have to be realistic. If we don’t make changes now, we will face a funding crisis.”

While the Government has dumped the idea of a GP co-payment, Ms Ley nevertheless said the current fee-for-service model of GP remuneration had to change.

“We need to shift from a fragmented system based on individual transactions, to a more integrated system that considers the whole of a person’s health care needs,” she said. “Innovative and blended funding models will be needed to provide appropriate care for patients with complex, ongoing conditions.”

In a warning for adherents of the current fee-for-service model, this is one area of health policy where there appears to be bipartisanship.

In her speech to the AMA Conference, Shadow Health Minister Catherine King said that, “I don’t for a moment suggest we abandon fee-for-service,” but warned there needed to be a “serious conversation” about whether it was best serving patients and rewarding good care.

Ms King said there were hundreds examples across the country of practices providing innovative and preventive care, often involving multidisciplinary teams led by GPs, but “the system as it works at the moment…does not provide incentives to reward this sort of activity. Nor does it reward outcomes”.

The issue of GP funding was the focus of a separate policy session at the Conference (see Providing high quality care doesn’t pay, px), where several presenters expressed concern of any change to funding arrangements that was not backed by sound evidence.

Among the speakers, AMA Victoria President Dr Tony Bartone said there was as yet no substantiated claim that alternative funding arrangements would deliver better patient outcomes than the fee-for-service model.

But Ms Ley said part of the change was aimed at ensuring better care for patient with complex and chronic conditions, as well as those with mental health problems.

She added that the Primary Health Networks being set up to replace Medicare Locals would be funded to “commission health and medical services to fill gaps”.

The Commonwealth has been heavily criticised for last year’s decision to axe the popular Prevocational General Practice Placements Program and abolish General Practice Education and Training, but at the Conference Ms Ley announced that competitive tenders for general practice training had opened. Successful bidders will receive funding to administer the Australian General Practice Training program, including co-ordinating and overseeing placements for GP registrars.

Tenders close on 10 July, and successful bidders will be funded from 1 October this year to the end of 2018.

Adrian Rollins

Listen, hear, act: challenging medicine’s culture of bad behaviour

There is no place for humiliation, discrimination or any kind of harassment in medical education

A perfect storm occurs when a situation is exacerbated by a rare combination of events. In recent media reports, there has been a perfect storm of accusations of every kind of abuse levelled against the medical profession by some of its own. Abuse is not new. Few who have experienced medical training can honestly say we have never seen nor been victims of any form of bullying or humiliation throughout that process. But the rare exacerbation early this year was the separate deaths of four junior trainees, apparently by suicide, followed soon after by Dr Gabrielle McMullin’s comments about the sexual harassment of female surgical trainees.1

The tragic deaths of the young doctors triggered my recent article in Croakey;2 but before that there was a long-brewing frustration fuelled by endless stories from students and doctors — of sexual harassment, bullying, teaching by humiliation, discrimination and the trauma of medical education — and by my own experiences of being a woman in medicine.

One reader’s comment in Croakey was particularly confronting.

The saddest part of this story is … deja vu. This has been happening intermittently for decades. A lot of noise is made about it, promises are made, and then after a few “death free” years everyone moves on — until tragedy strikes again.3

Looking back over nearly four decades since I entered medical school, I know my reader is right: much is said, but little changes. Well intentioned programs, policies and services are in place, but, as the reader continued,

one of the biggest impediments to seeking help is that the young doctors would be seeking help within their own system and are too ashamed to do so.

The services, supports and reporting pathways are there, so why don’t doctors use them? Perhaps the strongest example of why not was revealed by McMullin’s suggestion that female surgical trainees who are asked for sexual favours by senior colleagues should oblige rather than risk their careers. The ensuing uproar suggests McMullin is an astute media tactician. Despite the vocal insistence of medical organisations to the contrary, McMullin stood firm that current systems are not solving the problem.

This is not a problem only for women or surgeons. My inbox was flooded with stories from women and men experiencing harm at the hands of colleagues and the system. One male intern wrote:

If I had known back then what I know now there is no way I would have chosen to do Medicine. In fact, the choice to do Medicine is the single biggest regret of my life … there are some real a**holes still out there; and I am at a loss as to how they can still be employed, given how completely unacceptable and out-of-line their behavior is.

A male senior student wrote,

I suffered terrible and sustained abuse and humiliation at the hands of a [specialist] physician culminating in my attempted suicide … The mental scars inflicted by him, and others … are, however, still painfully present … I strongly considered abandoning medicine altogether … because of the culture of abuse that is still inherent.

The Royal Australasian College of Surgeons,4 the Australian Medical Association5 and the Victorian Health Minister6 have now all weighed in with a range of proposed reviews and taskforces. Frank and fearless examination of current processes is welcome, but it must genuinely aim to remove the significant barriers to doctors using them without personal peril. Negative impacts on the right to practise and on career progress are among the most common reasons doctors cite for not seeking treatment or support for mental health conditions.7

What needs to change most is a medical culture that condones and even encourages bad behaviour. That will not happen through advisory panels and external forces. Medicine is a complex, multicultural affair: a loose coalition of high-achieving, competitive individuals belonging to numerous workplaces and associations, each with its own internal hierarchies and cultures. No single person in medicine has the power that the former Chief of Army, Lieutenant General David Morrison, displayed in his unequivocal response to sexual harassment in the army.8 Also unlike soldiers, doctors are trained to work autonomously: to give, rather than take, orders.

For most of the past two centuries, doctors stood atop the health care pyramid and enjoyed enormous autonomy and deference. But as society began to change after World War II, so too did medicine.

More women entered medicine, and gender parity among students occurred around the mid 1970s. And yet, that gender balance is still not reflected in most specialist training schemes or in the medical workforce where the ratio of women to men is 2 : 5.9 More worryingly, selection criteria seem once more to be favouring male students.10

Consumers began to demand more say in their care and increasingly held doctors to account; legislation and external regulatory bodies became more prominent in governing doctors’ actions; non-medics took over hospitals; and interdisciplinary teams became the new work paradigm. However, the training and expectations of doctors to be on top of the pyramid remain largely unchanged. I wonder if some of the bad behaviour we see is symptomatic of a profession struggling to adapt to lost status. Cultural change is difficult, and resistance is common.

Whatever the cause of medicine’s discontent, for change to start, we must first accept that we have allowed a workplace culture in which incivility and frank bullying are commonplace. There are too many deniers and too much victim shaming in the current commentary. “It didn’t happen to me, therefore it didn’t happen”, is not evidence. Simply suggesting junior doctors develop “resilience strategies” and “stand up to bullies” is further victim blaming.11

Bad behaviour is often unconscious. Like evil, it is banal and takes hold when the unthinkable becomes normalised as the way things are and people fail, for fear or favour, to challenge the status quo.12 The belief that, to succeed, it is necessary to acculturate to, accommodate and perpetrate this negative culture is, sadly, all too common. It’s time to stop talking and harness one of medicine’s most powerful and underused diagnostic skills: listening. All the taskforces and policies in the world will not make an iota of difference if the victims’ voices are silenced by fear or shame.

Change is most successful if it’s modelled from the top. As medicine has no single chain of command, leaders committed to genuine change must be championed and supported to implement a zero-tolerance approach. Training in respectful communication could be made mandatory for all teachers and supervisors. Feedback and appraisal mechanisms can be built into performance reviews and accreditation processes. Providing an independent regulatory authority such as a health workplace ombudsman13 deserves serious consideration as a safe pathway for raising concerns and getting support, and for removing those in power who refuse to change.

It is possible to learn skills to improve your ability to communicate and to model positive behaviour. At the University of Sydney, for example, we are developing workshops to train health professionals in acting skills. Actors are able to be fully engaged within a role while also observing their own performance and adapting it to the situation. By practising these skills, doctors can start to recognise the impact of their actions on others and to safely challenge the normalisation and perpetuation of bad behaviour.

But real change also requires each of us to listen to our conscience and ask, “Am I part of the problem?”. It requires individuals to challenge “the way things are” so that reporting bad behaviour becomes everyone’s responsibility, not just the victims’. The consequences of bullying and harassment are reduced concentration, anxiety, compromised communication and poor team work. Shooting the messenger does great harm. It is killing both doctors and patients. What we cannot allow to happen is for the prediction of my reader to come true:

when this all “blows over” I’m sure the next crop of young doctors will be in the same boat.

Medibank abandons controversial GP trial

Giant insurer Medibank Private has abandoned a controversial scheme for preferential access to GPs for its members, but is pushing ahead with a pilot program for closer collaboration with doctors in the care of patients with chronic disease.

In a discreet announcement six months after its public float, the nation’s largest health fund revealed on 22 May that it had “redefined its involvement in primary care”, and would scrap the trial of its GP Access program on 31 July.

Under the program, trialled at 26 GP clinics in Queensland for the past 18 months, Medibank members were guaranteed same-day appointments and after hours GP home visits.

It was heavily criticised by the AMA and other health groups who said it undermined the universality of care and the principle that patients should be treated on the basis of need rather than income or affiliation.

Announcing the decision, the insurer’s Executive General Manager, Provider Networks and Integrated Care, Dr Andrew Wilson, said that although the 13,000 members who had used the service were pleased with it, “they did not feel it added additional value to their private health insurance”.

Dr Wilson said the fierce reaction of the AMA and other groups had also weighed on the decision to scrap the program.

“Disappointingly, it was clear from the feedback that this pilot was perceived as a first step towards the creation of a two-tier or exclusive health system,” he said. “Medibank is a strong supporter of universal health care, and we would certainly hate people to think that we were trying to do anything like this.”

Instead, the insurer is turning its focus to a scheme for closer collaboration with GPs in caring for members with chronic and complex conditions.

Last September it launched a pilot of its CareFirst chronic disease management scheme at six clinics in south-east Queensland, under which GPs receive payments to enrol patients with chronic health problems including heart failure, COPD, osteoarthritis and diabetes into a program that includes a care plan, health coaching and online education. Doctors are awarded incentives for improvements in patient health.

Medibank said that so far more than 200 patients had been enrolled, and early results were promising.

“Stakeholders also told us that GPs feel stretched and unable to provide the longitudinal care they’d like to be able to provide their patients battling chronic illnesses and complex health issues,” Dr Wilson said. “Through both our CareFirst and Care Point pilots we are now working closely with GPs so they can do more for their patients, particularly in tackling chronic disease and keeping people out of hospital.”

Adrian Rollins

AMA wants to recruit pharmacists to primary health team

Patients would suffer fewer adverse reactions to medicine and be almost $50 million better off while governments would save more than $500 million under an AMA plan to integrate pharmacists into general practice.

In a major pitch to improve patient care, reduce unnecessary hospitalisations, and boost cost-effective GP-led primary care, the AMA has developed a proposal to employ non-dispensing pharmacists in medical practices.

It is estimated that a quarter of a million hospital admissions each year are related to the use of prescription drugs, costing the country $1.2 billion, while around a third of patients fail to comply with directions for taking their medicines, undermining their health, causing adverse reactions and wasting taxpayer dollars.

AMA President Associate Professor Brian Owler said that integrating non-dispensing pharmacists within general practices as part of a GP-led multidisciplinary health team could go a long way to addressing these problems, improving patient health and cutting costs.

“Under this program, pharmacists within general practice would assist with things such as medication management, providing patient education on their medications, and supporting GP prescribing with advice on medication interactions and newly available medications,” A/Professor Owler said. “Evidence shows that the AMA plan would reduce fragmentation of patient care, improve prescribing and use of medicines, reduce hospital admissions from adverse drug events, and deliver better health outcomes for patients.”

The proposal, developed in consultation with the Pharmaceutical Society of Australia, could prove a game-changer in fostering closer collaboration between GPs and pharmacists.

It has come amid a concerted push by some in the pharmaceutical sector to encroach upon areas of medical practice in an effort to offset declining revenues from dispensing medicines, including authorising pharmacists to administer vaccines and conduct health checks.

The AMA has warned governments that allowing pharmacists to practise outside their field of expertise could put patients at risk, undermine continuity of care and increase health costs.

The AMA stressed that under its new proposal, pharmacists working within general practices would not dispense or prescribe drugs, nor issue repeat prescriptions, and would instead focus solely on medication management, including advising GPs on prescribing, drug interaction and new medicines, reviewing patient medications and monitoring compliance, improving coordination of care for patients being discharged from hospital with complex medication regimes, and ensuring the safe use and handling of drugs.

The proposal calls for medical practices to be awarded Pharmacist in General Practice Incentive Program (PGPIP) payments similar to those to support the employment of practice nurses.

The AMA has proposed that practices receive an incentive payment of $25,000 a year for each pharmacist employed for at least 12 hours 40 minutes a week, capped at no more than five pharmacists, meaning practices can receive no more than $125,000 a year – except those in rural and remote areas, which would be eligible for a loading of up to 50 per cent.

An independent analysis of the proposal commissioned by the AMA and conducted by consultancy Deloitte Access Economics estimated that if 3100 general practices joined the PGPIP program it would cost the Federal Government $969.5 million over four years.

The consultancy said that the average annual pharmacist salary was $67,000 plus on-costs, meaning only clinics treating 3000 or more standardised whole patient equivalents (an age-weighted measure based on GP and other non-referred consultation items in the MBS) would be likely to participate.

But the Deloitte report said the outlay would be more than offset by substantial savings in other areas of the health system, calculating that for every $1 invested in the PGPIP, taxpayers would save $1.56 in other areas of the health system.

In particular, Deloitte estimated that, as a result of the program:

a drop in the number of patients hospitalised because of adverse reactions to medications would save $1.266 billion;
fewer prescriptions subsidised through the PBS because of better use of medicines would save $180.6 million;
patients would save $49.8 million because of fewer prescriptions and the attached co-payments; and
Medicare would save $18.1 million because fewer patients would see their GP as a result of an adverse reaction to their medicine.

In all, Deloitte said the initiative would deliver a net saving of $544.8 million over four years for the health system, and the benefit-cost ratio improves with each year the scheme is in operation.

“The policy will likely to lead to improved compliance and persistence with medication regimens, which will result in improved health outcomes for patients,” the Deloitte report said. “This will result in significant avoided financial and economic costs for both the patient and the health system, as well as avoided broader economic costs such as lost productivity that arise when a health condition is treated and managed sub-optimally.”

The Deloitte report can be found at article/general-practice-pharmacists-improving-patient-care

Adrian Rollins

Budget small business tax concessions – what they mean for doctors

Many doctors stand to gain from Federal Government changes to small business taxation arrangements announced in the Federal Budget, according to accounting expert Jarrod Bramble.

Mr Bramble, a partner in New South Wales-based accounting firm Cutcher & Neale, said medical practitioners in private practice, visiting medical officers with fee for service, sessional fee or simplified billing arrangements, and staff specialists with rights of private practice were all in a position to take advantage of small business concessions outlined in the budget, including a 1.5 percentage point tax cut and a $20,000 instant asset write-off.

Mr Bramble that practitioners operating as a small business with an aggregated annual turnover of less than $2 million would be eligible for an immediate write-off of assets purchased after Budget night that cost less than $20,000.

“Tax planning has never been simpler,” he said. “[It] means, in most cases, an item purchased for less than $22,000, including GST, will receive a GST credit of $2000 and benefit from a tax saving of $9800. This effectively halves the cost of new plant and equipment, as well as motor vehicles.”

The arrangement will be in place until 30 June 2017.

Mr Bramble said that assets pooled in prior years with a closing balance of $20,000 or less during the two years from 30 June 2015 will also be eligible for the immediate write-off.

The change also means that professional expenses incurred in setting up a practice will, from 1 July, be immediately deductible, where previously they had to be written off over five years.

Practitioners who operate using an eligible corporate structure (including an annual aggregated turnover of less than $2 million) would also receive a cut in the company tax rate from 30 to 28.5 per cent and, where a medical professional carries on the business as an individual, they would be eligible for a maximum $1000 rebate.

But Mr Bramble warned proposed changes to fringe benefits tax arrangements would impose a $5000 cap on the FBT exemption for meal and entertainment expenses, affecting the salary packaging benefits for public and not-for-profit hospital staff.

The Government intends to impose the cap from 1 April next year, giving doctors just 10 months to maximise the benefit of current arrangements, Mr Bramble said.

The accountant also urged doctors to use vehicle log books if they wanted to be able to claim more than a maximum annual deduction of $3300.

He said deductible trips for a log book included travel between hospitals, journeys from home to a patient’s house and then to a practice, trips between a practice and a hospital, doctors on call who have dispensed advice from home before travelling, and travel to conferences, workshops and other education events.

Mr Bramble also noted that the Government’s four-year freeze on Medicare rebates meant by mid-2018 their value would be 7 per cent less than now.

Adrian Rollins

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.

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.