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.

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

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

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

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

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

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

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

Methods

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

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

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

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

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

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. Therefore, we could not assess the statistical significance of differences with the Australian ITC Project results. The results for daily smokers in the Australian ITC Project were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

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

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

Results

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

Strengths and limitations

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

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

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

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

Indicator of dependence

Talking About The Smokes project, % (frequency)†

Australian ITC Project,
% (95% CI)‡

Cigarettes per day

1–10

40% (547)

33.4% (27.9%–39.3%)

11–20

39% (528)

42.2% (36.8%–47.7%)

21–30

18% (242)

18.5% (14.7%–22.9%)

≥ 31

4% (54)

6.0% (3.7%–9.6%)

Time to first cigarette

More than 60 minutes

9% (125)

16.1% (11.9%–21.3%)

31–60 minutes

16% (220)

19.4% (15.3%–24.2%)

6–30 minutes

64% (884)

46.7% (41.2%–52.3%)

5 minutes or less

11% (145)

17.9% (13.6%–23.2%)

Heaviness of Smoking Index (HSI) score

Low (0–1)

17% (234)

24.5% (19.5%–30.3%)

Moderate (2–3)

59% (796)

44.6% (39.2%–50.1%)

Heavy (4–6)

24% (328)

30.9% (25.8%–36.5%)

How often do you get strong urges to smoke?

Never or less than daily

21% (291)

12.4% (9.0%–16.9%)

Daily

27% (375)

26.9% (21.9%–32.5%)

Several times a day or more often

51% (706)

60.7% (54.9%–66.2%)

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

Very or somewhat easy

17% (234)

10.4% (6.9%–15.4%)

Neither easy nor hard

11% (156)

7.9% (5.0%–12.2%)

A little bit hard

32% (439)

33.7% (28.8%–39.0%)

Very hard

39% (537)

47.9% (42.3%–53.6%)

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

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

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

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

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

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

Indicator of dependence	Daily smokers, % (frequency)*

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

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

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

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

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

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

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

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

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

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

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

Methods

The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people using a quota sampling design in the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait, and has been described elsewhere.8,9 Briefly, the 35 sites were selected based on the geographic distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or ex-smokers who had quit ≤ 12 months before, and 25 non-smokers, with equal numbers of women and men and in each of two age groups (18–34 and ≥ 35 years). In four major-city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged less than 18 years, not usual residents of the area, staff of the ACCHS, or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). There were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.8 A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed at each site.

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

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

Statistical analyses

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

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

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

Results

Smoke-free homes

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

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

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

Smoke-free workplaces

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

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

Association with quit attempts and wanting to quit

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

Discussion

Smoke-free homes

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

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

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

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

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

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

Smoke-free workplaces

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

Association with quit attempts and wanting to quit

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

Strengths and limitations

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

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

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

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

1 Smoking bans in homes and workplaces*

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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