more_vertThe history of anthropology exhibitions and ethnographic museums exposes an unpleasant colonial past, and exhibitions of Indigenous Australian culture in Europe are among the worst. European anthropology exhibitions are grounded in the tradition of the 19th-century World’s Fair, which brought travel and cultural voyeurism to the masses by plundering local people and sometimes putting them on display in a freak show setting. Fortunately, anthropology as a discipline changed for the better in the 20th century, and in recent decades many international institutions started to employ curators from Indigenous communities to manage and interpret their collections appropriately, including the British Museum.
Preference: Indigenous Health
1
The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015
The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015 is the eighth in a series of reports that provide a comprehensive statistical picture of a range of topics considered important for improving the health and wellbeing of Indigenous people. The report presents up-to-date statistics, as well as trend information. It examines differences between Indigenous and non-Indigenous Australians, as well as differences by factors such as age, sex and, in particular remoteness.
Sky-high Indigenous imprisonment rates a health disaster
Imprisonment is rarely good for health, particularly if you are an Indigenous Australian.
But, tragically, Indigenous people are far more likely to be locked up than other Australians, exacerbating health problems and sending many into a downward spiral of illness and premature death.
The figures are stark.
In 1991, the Royal Commission into Aboriginal Deaths in Custody identified extraordinary rates of incarceration among Indigenous Australians compared with the rest of the community, and established a link with poor general and mental health.
But, despite the Royal Commission’s recommendations, the situation has got significantly worse.
Among Aboriginal and Torres Strait Islanders, the adult imprisonment rate soared 57 per cent between 2000 and 2013, while juvenile detention rates increased sharply between 2000-01 and 2007-08, and have fluctuated ever since at around 24 times the rate for non-Indigenous youth.
Currently, almost a third of all prisoners are Aboriginal, including 48 per cent of juveniles held in custody.
Not only that, but the rate of reoffending is astronomical. In fact, repeat offending and re-incarceration is a large contributor to this high rate of imprisonment.
Shocking though these statistics are, they do not begin to describe the suffering and distress experienced by incarcerated Indigenous people, their families and communities.
Mental illness and mental health problems, including alcohol and drug abuse, contribute significantly to their rates of imprisonment and recidivism.
Being incarcerated, in turn, exacerbates existing conditions in prisoners. And, without appropriate and effective treatment within prison, mental illness and mental health issues are a major factor in poor outcomes for people released from prison, including suicide, death from overdose or injury and reoffending.
Social disadvantage and a history of upheaval culminating in trauma and grief clearly contribute to the high level of imprisonment among Indigenous Australians.
Many studies published since 2000 have highlighted that Aboriginal people already have a higher prevalence of significant psychological distress when compared to the non-Aboriginal population, disrupting social and emotional wellbeing and causing post-traumatic stress disorder, depression and substance abuse.
Alcohol is well-known as a common precursor to offending among Indigenous Australians, with indications that it could be a factor in up to 90 per cent of all Indigenous contacts with the justice system.
Once incarcerated, Aboriginal prisoners are at greater risk of developing or exacerbating a mental illness. Ninety-three per cent of Aboriginal women in jail, and 81 per cent of men, have some form of mental illness. Altogether, 30 per cent of Aboriginal women and 20 per cent of Aboriginal men in jail have attempted suicide, and 33 per cent of Aboriginal women and 12 per cent of Aboriginal men suffer from post-traumatic stress disorder.
It is apparent that there is a complete lack of appropriate services to meet complex social, cultural and health needs.
A clearer understanding of some of the drivers of incarceration of Aboriginal and Torres Strait Islander men and women is needed, as are better interventions through culturally appropriate health and disability services before entering custody, during imprisonment, at the time of release and post-release.
There are several things that can and should be done to end this vicious cycle of illness, abuse and incarceration for Indigenous people, including making it much easier for Indigenous offenders to get into diversion programs for alcohol and drug-related offences; establishing Indigenous-specific diversion programs linked to Aboriginal community controlled services; improving the level of health services for Indigenous prisoners; comprehensive health screening for those entering prison, and channelling them into appropriate treatment; and research and develop performance indicators to guide effective health services for Indigenous offenders.
These matters will be considered in the AMA’s Indigenous Health Report Card, which will be released later this year.
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 |
Yes |
No |
Don’t know |
|||||||||
|
|
|||||||||||||||
|
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 |
58% (325) |
37% (209) |
5% (31) |
4.96 |
|||||||
|
Very much |
80% (177) |
18% (40) |
2% (4) |
13.58 |
74% (164) |
23% (51) |
3% (7) |
10.26 |
|||||||
|
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 |
75% (112) |
21% (31) |
4% (6) |
3.43 |
|||||||
|
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 |
78% (72) |
17% (16) |
4% (4) |
4.09 |
|||||||
|
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 |
48% (157) |
45% (147) |
7% (22) |
0.83 |
|||||||
|
|
|||||||||||||||
|
* 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.
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.16
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.
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 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. |
|||||||||||||||
Tobacco control policies and activities in Aboriginal community-controlled health services
Aboriginal community-controlled health services (ACCHSs) have long recognised tobacco use as an important contributor to poor health outcomes in their communities,1 and have worked to reduce this burden with a range of tobacco control initiatives. The ACCHS sector includes about 150 health services across Australia, each governed and managed by its local Aboriginal community, as well as representative state or territory organisations (Affiliates) and the National Aboriginal Community Controlled Health Organisation (NACCHO).
In 2001, NACCHO surveyed 67 staff from Aboriginal health services, 124 Aboriginal and Torres Strait Islander community members from 13 locations, and 76 health services with predominantly Aboriginal and Torres Strait Islander clients.2 The survey identified high levels of knowledge about the harmful health effects of tobacco, a lack of specific tobacco control programs and the need for more information on effective stop-smoking interventions. The report recommended that governments prioritise and fund tobacco control through policies that deal with social determinants of smoking, workforce training, comprehensive long-term programs to reduce smoking, and ongoing evaluation. For ACCHSs, the report recommended making tobacco control a specific priority and integrating it into health service programs.
Since 2001, specific tobacco control programs have been widely implemented in ACCHSs, informed by evidence from individual evaluations and randomised controlled trials of Aboriginal tobacco control interventions,3–5 and literature reviews.6–9 ACCHSs have also learnt from each other by sharing examples of what has (or has not) worked well.10–12
In 2008, the federal government increased support through the $14.5 million Indigenous Tobacco Control Initiative over 3 years, followed in 2009 by a $100.6 million commitment over 4 years to the Council of Australian Governments’ Tackling Indigenous Smoking measure.13,14 These funded social marketing, quit support and other programs, with the goal of halving smoking rates in Aboriginal and Torres Strait Islander communities by 2018. Forty ACCHSs and three NACCHO Affiliates received funds for tobacco control activities under these initiatives. Smoke-free workplace policies for ACCHSs and other organisations delivering Aboriginal primary health care were mandated in funding contracts with the Australian Government from July 2012.15
These tobacco control activities occurred in the wider Australian context of expanding smoke-free legislation, increases in tobacco taxation, plain packaging of cigarettes and ongoing social marketing campaigns.
The Talking About the Smokes (TATS) project, part of the International Tobacco Control Policy Evaluation Project, aims to assess the impact of tobacco control policies on the Aboriginal and Torres Strait Islander population. Here, we describe the tobacco control policies, activities and programs reported by the ACCHSs participating in the TATS project.
Methods
The TATS project involved 35 communities served by 34 ACCHSs and one community in the Torres Strait where there is no ACCHS and health services are provided by Queensland Health. ACCHSs were selected to reflect the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. The methods are described in detail elsewhere.16,17
Briefly, at 30 sites, we aimed to survey up to 50 smokers or ex-smokers who had quit ≤ 12 months before and 25 non-smokers, with equal numbers of men and women and those aged 18–34 years and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. Between April 2012 and October 2013, trained local interviewers completed the 30–60 minute community surveys face to face using a computer tablet. The community sample closely matched the distribution of age, sex, jurisdiction, remoteness and number of cigarettes smoked per day reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17
The TATS project also invited representatives at each site to complete a single policy monitoring survey, including questions about health service size and location; tobacco control funding, resources and policies; cessation support; and advocacy. The policy monitoring surveys were paper-based, designed to take less than 10 minutes, and were completed by staff members selected by the ACCHS. Policy monitoring surveys were completed while community surveys were being conducted at that site. Questions from the policy monitoring and community surveys analysed here are listed in Appendix 1.
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 report the numbers of ACCHSs with different levels of tobacco control resourcing, activities and smoke-free policies; and the percentage and frequency of community members supporting smoking bans. Using the χ2 test, we assessed variation between services by size of service (< 50 or ≥ 50 staff); whether the service had received dedicated tobacco control funding in the past year; and its reported prioritisation of tobacco control in the past year (“not at all”, “just a little”, “a fair amount” or “a great deal”).
At the first project site, the question about prioritisation of tobacco control was not asked, and two questions about dispensing and prescribing free nicotine replacement therapy were asked as a single question. Less than 0.5% of respondents to the community survey did not answer the questions about smoking bans. These missing values were excluded from our analyses. We also excluded results from the Torres Strait community without an ACCHS.
Results
The 32 completed policy monitoring surveys describe tobacco control activities at 34 sites, as a single survey was completed by the umbrella ACCHS for three participating sites in one area. Nineteen services had 50 or more staff and 13 had fewer than 50.
Tobacco control resourcing and activities at ACCHSs
Nineteen of 32 ACCHSs reported receiving specific funding for tobacco control programs in the past 12 months. Another three used untied funds for tobacco control programs. Dedicated tobacco control funding was not associated with the size of the ACCHS (P = 0.84) or its reported prioritisation of tobacco control (P = 0.19). Thirteen ACCHSs reported prioritising tobacco control a great deal, 11 a fair amount and seven just a little. Eighteen ACCHSs had a staff position with a major focus on tobacco control.
Staff of 27 services had attended tobacco control training in the past year. There was no association between staff attending training and the size of the service (P = 0.31) or dedicated tobacco control funding (P = 0.34). However, there was an association with the prioritisation of tobacco control (P = 0.04), with some staff attending training at all 13 ACCHSs that had prioritised it a great deal. The training had been provided by a range of organisations, including NACCHO Affiliates, the Centre for Excellence in Indigenous Tobacco Control, cancer councils, quit organisations and state health departments.
In the past 12 months, 17 of 32 services had run programs to help people quit smoking. These included Aboriginal-specific tobacco control and healthy lifestyle programs, as well as mainstream quit programs. In all but one of these services, Aboriginal health workers or tobacco action workers were involved in running the program. Programs had been evaluated in nine services, some with internal surveys and others with the assistance of NACCHO Affiliates or universities.
Free nicotine replacement therapy was prescribed or dispensed by 25 of the 32 services. Most ACCHSs (21/34) supported staff who smoked by providing them with extra smoking cessation support, either by facilitating access to programs available to clients or through specific programs for staff.
Smoke-free workplace policies
All ACCHSs reported having a formal smoke-free policy in place. The features of these policies and the reported levels of adherence are described in Box 1. In contrast, only 18 of 32 services reported that most or all other Aboriginal and Torres Strait Islander organisations in their community were smoke-free; 10 reported that some were smoke-free and four that none were.
Community survey respondents (n = 2435) reported a high level of support for smoking bans everywhere at ACCHSs and indoors at other Aboriginal organisations, with less (but still majority) support for bans at outdoor community events (Box 2). Among the daily smokers who did not support total bans at ACCHSs, 82% (251/306) supported indoor bans. Daily smokers were least likely to support any of the bans.
Health promotion
All 32 ACCHSs provided locally or externally produced quit-smoking information to their communities, most commonly using posters, pamphlets and displays at information days or other community events, but also using newer media such as the internet and social media (Box 3). Health services with dedicated tobacco control funding were more likely to use locally developed posters (P = 0.03) and pamphlets (P = 0.02) in the clinic, and to give pamphlets to other organisations (P = 0.02), but there were no significant associations with funding when these locally developed items were considered together with externally developed information, or for other types of information. Ten services reported smoking or quitting stories featuring someone from their health service in mainstream or Aboriginal and Torres Strait Islander television, radio or newspaper news.
Nineteen ACCHSs reported discussing tobacco control policy at meetings with government and non-government organisations in the previous year, with 11 reporting that they had influenced local, regional or national tobacco control policy.
Discussion
We found that tobacco control initiatives are a priority in ACCHSs, with all reporting smoke-free workplace policies to reduce smoking and exposure to second-hand smoke. Staff with specific tobacco control training are providing a range of evidence-informed quit-smoking programs in health services and in the wider Aboriginal and Torres Strait Islander community. This increased tobacco control activity was not just found in health services with dedicated Aboriginal and Torres Strait Islander tobacco control funding.
Elsewhere in this supplement, we show that more community members from sites with dedicated tobacco control resources had been advised to quit,18 recalled noticing cigarette pack warning labels,19 made quit attempts20 and used stop-smoking medicines21 than those from sites without dedicated resources. However, there were no such significant differences for wanting to quit,22 smoke-free homes,23 recalling advertising and news stories about smoking and quitting,19 and personal attitudes towards smoking.24
A limitation to our study is that although the selected ACCHSs are geographically representative of the Aboriginal and Torres Strait Islander population, the ACCHSs that responded to the call for participation are likely to be biased towards those that were more interested and active in tobacco control. Further, the people completing the policy survey may have been unaware of all services and policies or may have overstated what was being provided. It was difficult to categorise services by their level of tobacco control activity because of the differences in the range of activities offered. Consequently, it was not possible to detect a relationship between dedicated funding and level of tobacco control activity. Furthermore, the small number of health services in our study did not allow identification of enablers and barriers to services prioritising tobacco control work, a useful area to explore in future research.
Our findings on smoke-free policies are not surprising, given implementing smoke-free work environments became a condition of funding for ACCHSs at the same time this study was conducted.15 However, it is likely that some aspects of these policies pre-dated the funding requirement, given that all 76 Aboriginal health services surveyed in 2001 reported indoor smoking bans, with the policies of 32% of services including broader measures.2 Our results provide evidence that many ACCHSs have more comprehensive policies, such as banning staff from smoking with clients and other staff or where they can be seen or while in uniform, and the provision of cessation support for staff. The incremental approach of ACCHSs in developing and strengthening policy content and implementation has common ground with government approaches to tobacco control, where success with indoor smoking bans was followed by an emphasis on initial exceptions, such as pubs and prisons, and on outdoor areas such as outdoor dining areas and street malls.25
The high level of community support for smoking bans that we found may reflect the wider tobacco control environment and the active involvement of ACCHS managers, staff and the community in tobacco control over the preceding decade. ACCHSs reported that policies relating to smoking behaviour of Aboriginal staff and the community have evolved over time, as the measures have been contested and negotiated in various Aboriginal community forums. This has included discussions about the right to smoke and the right to be protected from second-hand smoke, the social inclusion of sharing cigarettes and the significance of denormalising smoking and modelling healthier behaviour to children.11,26
The relatively small size of many ACCHSs provides an environment to test out policy measures that can then be either discarded as unacceptable or ineffective, or promoted as successful measures to other Aboriginal, community and health organisations. A key characteristic of ACCHSs is that a community with a high prevalence of smoking is involved in making and implementing decisions in areas they can control, such as workplaces and community events, thus providing Aboriginal leadership and contributing to shifts in social norms in their community. Aboriginal health services are well placed to influence social norms because of the large number of Aboriginal and Torres Strait Islander people who work there and use their services — 3618 full-time equivalent staff and 314 000 clients in 2012–13.27 There is an opportunity for ACCHSs to influence other Aboriginal and Torres Strait Islander organisations in their communities that do not have smoke-free policies.
It would be useful to monitor the diffusion of the successful and innovative tobacco control work both within and beyond the ACCHS sector, and to look to ACCHSs for new ideas in the future. The high level of commitment and experience in ACCHSs provides a strong base for sustainable interest and activity to further reduce smoking levels and smoking-related harm.
1 Smoke-free policies at health services (n = 32)
|
Policy details |
Health services |
||||||||||||||
|
|
|||||||||||||||
|
Policy content |
|||||||||||||||
|
No smoking indoors |
32 |
||||||||||||||
|
Designated outdoor smoking area |
12 |
||||||||||||||
|
No smoking indoors or outdoors within the boundary/fence of health service |
28 |
||||||||||||||
|
No smoking in work vehicles |
32 |
||||||||||||||
|
No smoking in health service uniform |
18 |
||||||||||||||
|
No smoking in work time |
9 |
||||||||||||||
|
Other* |
5 |
||||||||||||||
|
How the policy was communicated |
|||||||||||||||
|
Written policy |
32 |
||||||||||||||
|
Signs |
28 |
||||||||||||||
|
Staff meetings and/or newsletters |
25 |
||||||||||||||
|
How many staff and clients follow all elements of the policy |
|||||||||||||||
|
Almost all |
17 |
||||||||||||||
|
Most |
11 |
||||||||||||||
|
Some |
3 |
||||||||||||||
|
Only a few |
1 |
||||||||||||||
|
|
|||||||||||||||
|
* Such as no staff smoking with clients or other staff, when offsite in an official capacity or outside designated meal breaks. |
|||||||||||||||
2 Aboriginal and Torres Strait Islander community support for smoke-free environments (n = 2435)*
|
Smoking ban |
Daily smokers (n = 1342) |
Non-daily smokers (n = 233) |
Ex-smokers (n = 299) |
Never-smokers (n = 561) |
|||||||||||
|
|
|||||||||||||||
|
Smoking should be banned everywhere at ACCHSs |
77% (1030) |
85% (197) |
85% (255) |
87% (487) |
|||||||||||
|
Smoking should be banned indoors at other Aboriginal organisations |
93% (1242) |
93% (217) |
95% (284) |
97% (544) |
|||||||||||
|
Smoking should be banned at outdoor festivals and sporting events |
51% (687) |
70% (163) |
65% (194) |
71% (398) |
|||||||||||
|
|
|||||||||||||||
|
ACCHSs = Aboriginal community controlled health services. * Results are based on the respondents who “agree” or “strongly agree” with each statement and exclude those who did not answer. |
|||||||||||||||
3 Health services using different media to disseminate quit-smoking information (n = 32)
|
Quit-smoking information |
Health services |
||||||||||||||
|
|
|||||||||||||||
|
Posters in clinic |
31 |
||||||||||||||
|
Pamphlets in clinic |
29 |
||||||||||||||
|
Health information days and events |
28 |
||||||||||||||
|
Displays at other community events |
26 |
||||||||||||||
|
Posters in other community locations |
23 |
||||||||||||||
|
Pamphlets given to other organisations |
21 |
||||||||||||||
|
Newsletters |
18 |
||||||||||||||
|
Website |
14 |
||||||||||||||
|
Social media |
12 |
||||||||||||||
|
Newspaper or community magazine |
11 |
||||||||||||||
|
Local radio advertisement |
11 |
||||||||||||||
|
CD/DVD |
11 |
||||||||||||||
|
Local television advertisement |
2 |
||||||||||||||
|
Mobile phone messages |
2 |
||||||||||||||
Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people
Fifty years since the United States Surgeon General’s first report on smoking and health, smoking prevalence has reduced globally,1 in part due to increased public awareness that smoking causes death and disease.2,3 However, it is possible that gaps in knowledge are contributing to health inequalities.4,5 In Australia, the prevalence of daily smoking has declined to just over 16% among adults but is higher in disadvantaged populations.6 Among the Aboriginal and Torres Strait Islander population, 42% of people aged 15 years or older smoked daily in 2012–2013.7 Understanding and tackling the causes of this disparity is a public health priority accepted by all Australian governments.8
Communicating information about the harmful effects of tobacco use is a major focus of programs to reduce smoking among Aboriginal and Torres Strait Islander peoples.9 Some evidence suggests that most Aboriginal and Torres Strait Islander people know that smoking causes lung cancer and heart disease,10–12 and that second-hand smoke (SHS) is dangerous.13–15 However, there is no current national research that describes knowledge of the harms of smoking and SHS exposure among Aboriginal and Torres Strait Islander smokers, or how it varies across this diverse population. Further, the extent to which lack of smoking-related knowledge contributes to the high smoking prevalence is unknown.
Greater knowledge and worry about future health effects of smoking have been shown to increase quit intentions and attempts in other settings.16–18 However, decisions to quit smoking are not one-dimensional, rational choices,19,20 and they may be obstructed by beliefs that diminish the likelihood or severity of smoking harms (risk minimisation).21,22 There has been some investigation into risk-minimising beliefs in Aboriginal and Torres Strait Islander tobacco control research. For example, perceived risk and worry may be low where there is discordance between information about the health consequences of smoking and the individual’s lived experience,14,23 or where there are fatalistic views of health effects that are perceived to be outside an individual’s control.12,24 This may explain why smoking persists in some contexts where knowledge of health effects is found to be high.
This is the first broadly representative description of smoking-related knowledge and health risk beliefs of Aboriginal peoples and Torres Strait Islanders. We also look at how this knowledge varies among smokers, and whether knowledge and health risk beliefs are related to quitting.
Methods
Survey design and participants
The Talking About The Smokes (TATS) project surveyed 2522 Aboriginal and Torres Strait Islander people (1643 current smokers, 311 ex-smokers and 568 never-smokers) from April 2012 to October 2013 (Wave 1, or baseline), and is described in detail elsewhere in this supplement.25,26 Briefly, we used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait (project sites), which were selected based on the population distribution of Aboriginal and Torres Strait Islander people by state or territory and remoteness. In most sites (30/35), we aimed to interview samples of 50 smokers (or ex-smokers who had quit ≤ 12 months before) and 25 non-smokers (never-smokers and ex-smokers who had quit > 12 months previously), with equal numbers of men and women and those aged 18–34 years and 35 years or older. The sample sizes were doubled in four major urban sites and in the Torres Strait community. People were excluded if they were: not Indigenous, not aged 18 years or older, not usual residents of the area, staff members of the ACCHS, or unable to complete the survey in English (if there was no interpreter available), or if the quota for the relevant age–sex–smoking category had been filled.
In each site, different locally determined methods were used to collect a representative, albeit non-random, sample. The baseline sample closely matched the sample distribution of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) by age, sex, jurisdiction and remoteness, and also number of cigarettes smoked per day for current daily smokers. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.25
Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey, entered directly onto a computer tablet, generally took 30–60 minutes to complete. A single survey of health service activities, including whether there were dedicated tobacco control resources, was completed for each site. The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees (Appendix 1).25
Survey questions
As the TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project), survey questions were based on ITC Project surveys previously used in Australia and New Zealand (http://www.itcproject.org/surveys). The exact questions used for this article are listed in Appendix 2.
Knowledge and health risk beliefs
Four questions assessed knowledge of the direct health effects of smoking among smokers and non-smokers — whether it causes lung cancer, causes heart disease, makes diabetes worse and causes low birthweight (answer options: “yes”, “no” or “don’t know”). Three questions assessed knowledge of the effects of SHS exposure — whether it causes asthma in children (“yes”, “no” or “don’t know”) and whether it is dangerous to non-smokers and to children (both assessed on a five-point scale from “strongly agree” to “strongly disagree”). We also computed two summary items, for correct responses to all four direct effects questions (“yes” to all) and correct responses to all three SHS measures (“yes” or at least “agree”).
Two items assessed health risk beliefs among smokers. Smokers who responded “agree” or “strongly agree” to the statement that “Smoking is not very risky when you think about all the things that people do” (assessed on a five-point scale from “strongly agree” to “strongly disagree”) were assessed as holding risk-minimising beliefs. Those who responded “very worried” to the question “How worried are you that smoking will damage your health in the future?” (assessed on a four-point scale from “not at all worried” to “very worried”) were assessed as having health worry.
Wanting and attempting to quit
Two quit-related outcomes were used: wanting to quit (“yes” or “no”) and having attempted to quit in the past year (“yes” or “no”), which was derived from questions on ever having tried to quit and timing of the most recent quit attempt.
Statistical analyses
Percentages and frequencies were calculated for all knowledge and health risk belief questions. Logistic regression was used to assess: (i) variation in correct responses among smokers, by daily smoking status, key sociodemographic variables, and presence of tobacco control resources at the local health service; and (ii) the association of knowledge and health risk beliefs with quitting interest and activity among smokers. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, identifying the 35 project sites as clusters, and the quotas based on age, sex and smoking status as strata.27 Both unadjusted and adjusted logistic regression analyses were performed, with daily smoking status and key sociodemographic variables included as covariates in the adjusted analyses. As unadjusted and adjusted calculations were very similar, only adjusted odds ratios (ORs) are reported here, with 95% confidence intervals.
Less than 1.5% of responses to each question were excluded (due to missing or refused responses), with the exception of quitting outcomes, which excluded a further 79 participants (4.8%) who did not know if they wanted to quit and 21 (1.3%) who did not know whether they had attempted to quit within the past year.
Results
Knowledge and health risk beliefs
Knowledge that smoking causes lung cancer and heart disease was high, and consistently over 90% of smokers and non-smokers knew about the harmful effects of SHS (Box 1). Knowledge that smoking makes diabetes worse was the lowest of all four direct effects, with 24% of daily smokers responding “don’t know” to this question (compared with 13% for low birthweight, 7% for heart disease and 3% for lung cancer). Among daily smokers, 44% held risk-minimising beliefs and 36% had health worry. Non-daily smokers had higher levels of risk-minimising beliefs and lower levels of health worry than did daily smokers.
Compared with daily smokers, non-daily smokers were more likely to respond correctly to all questions about the direct effects of smoking (OR, 1.79; 95% CI, 1.32–2.43; P < 0.001) and the harms of SHS (OR, 1.69; 95% CI, 1.08–2.62; P = 0.02) (Appendix 3).
There was some social patterning based on sociodemographic variables (Appendix 3). While knowledge of direct effects was significantly associated with employment and education, only area-level indicators were associated with both direct effects and SHS knowledge. Smokers were more likely to respond correctly to all questions if they were from a remote or very remote area (direct effects OR, 1.73; 95% CI, 1.16–2.57; SHS OR, 2.69; 95% CI, 1.61–4.52), compared with those from major cities, and smokers from an area of the highest level of disadvantage were more likely to respond correctly (direct effects OR, 1.83; 95% CI, 1.32–2.54; SHS OR, 1.33; 95% CI, 0.85–2.08) than were those from areas of least disadvantage.
Conversely, smokers from areas where the local health service had dedicated tobacco control staff or funding were less likely to respond correctly to all direct effects questions (OR, 0.64; 95% CI, 0.48–0.86) and all questions about the harms of SHS (OR, 0.58; 95% CI, 0.40–0.82), compared with those from areas where there were no dedicated resources (Appendix 3).
Relationship of knowledge and health risk beliefs with quitting
Smokers who responded correctly to all questions about harms of SHS were more likely to want to quit and to have attempted to quit in the past year, but those who responded correctly to questions about direct effects of smoking were not (Box 2). Similarly, smokers who responded correctly to all SHS knowledge questions were more likely to be very worried about their future health (OR, 4.74; 95% CI, 3.01–7.45; P < 0.001), but those with knowledge of all direct effects were not (Appendix 4). Those who were very worried about their health were more likely to want to quit and to have made a quit attempt in the past year (Box 2). Risk-minimising beliefs were not significantly associated with either wanting to quit or having attempted to quit in the past year.
Discussion
Our results show high levels of knowledge among Aboriginal and Torres Strait Islander people that smoking causes lung cancer and heart disease, along with strong awareness of the harms of SHS, consistent with previous tobacco control research in this population.10–14 Knowledge that smoking causes lung cancer and heart disease and is dangerous to others was assessed at very similar levels among Aboriginal and Torres Strait Islander daily smokers and those in the general population, based on comparable measures last assessed by Australian ITC Project surveys from 2002 to 2004.16,28
The main gap in knowledge, which has also been reported elsewhere,12 concerned the role of smoking in exacerbating diabetes. As Aboriginal and Torres Strait Islander people are more than three times as likely as non-Indigenous Australians to report a diagnosis of diabetes or high blood or urine sugar levels,7 with diabetes prevalence estimates ranging from 3.5% to 33.1%,29 this gap highlights the need for targeted education about the link between smoking and diabetes. This applies to clinicians as well as the broader Aboriginal and Torres Strait Islander population, particularly in light of updated evidence presented in the 2014 report of the US Surgeon General, which concludes that smoking increases the risk of developing type 2 diabetes in a clear dose–response manner.2
Our results also show a need to build knowledge that smoking causes low birthweight, which was either denied or not known by 18% of daily smokers, similar to previous findings.14,30 Messages that smoking causes lung cancer and heart disease and is dangerous to children have all featured on cigarette pack warning labels.31 Together with other sources of health information, such as mass media, news stories, local health promotion strategies and advice from health professionals, these are likely to have contributed to the high knowledge about these health effects among our Aboriginal and Torres Strait Islander participants.
Given health services are an important source of health information, it was surprising that knowledge was lower among smokers surveyed by sites with dedicated tobacco control resources. Though difficult to explain, this may be an indirect effect of the prioritisation of limited tobacco control resources to areas of greatest need, particularly as these resources included federally funded positions that had not long been established.9 Alternatively, it may suggest that information about the health effects of smoking is more effective when incorporated into established routine health service activities that include other areas of health and wellbeing.
Our findings suggest that gaps in knowledge are not responsible for the high prevalence of smoking or the social patterning of smoking among Aboriginal and Torres Strait Islander people. Contrary to the geographic and social patterning of smoking prevalence among Aboriginal and Torres Strait Islander people,7,32 we found that those from more remote and disadvantaged areas were more knowledgeable about the harmful effects of smoking and SHS. This is not to say that increasing knowledge is not important; prospective analyses from other ITC Project studies consistently show that knowledge, worry and risk beliefs contribute to motivation to quit.16,18,22,33 Though we have shown that knowledge is also related to interest in quitting among Aboriginal and Torres Strait Islander smokers, other factors are likely to be more important in influencing the success of quit attempts (and their translation to reduced prevalence), as found in other populations.17 For example, stress is commonly cited by Aboriginal and Torres Strait Islander smokers as a trigger for relapse,12,15,34,35 and it should be considered among other possible barriers including social normalisation of smoking, underlying social disadvantage, nicotine dependence and access to and uptake of services to support quitting.36
Among smokers, knowledge of SHS harms was associated with wanting to quit and attempts to quit, but knowing about direct, personal health consequences was not. Similarly, in an ITC Project survey in New Zealand, setting an example to children was more likely to be identified by Maori and Pacific peoples as a reason to quit, and was associated with SHS awareness and protective behaviour among smokers.37 Our findings are also consistent with qualitative research from the Northern Territory,15,24 in which Aboriginal participants expressed higher levels of concern for the health of others than for personal risk. Health is considered by many Aboriginal and Torres Strait Islander people to include the health of others.38 This may also explain why risk-minimising beliefs did not reduce interest in quitting, as predicted from research in the general population, despite being held at similar levels.21,22 It may be that these counterarguments are an ineffective shield to risks that include the health of others, and so have little or no effect on interest in quitting among Aboriginal and Torres Strait Islander people.
Our findings weaken the argument that risk-minimising beliefs explain why smoking persists in contexts where knowledge is high, and provide evidence that challenging these beliefs is unlikely to increase interest in quitting among Aboriginal and Torres Strait Islander people. Rather, health information may be interpreted with greater priority and relevance where negative health effects are framed in ways that include the health of others. This supports the approach used in the “Break the Chain” campaign, Australia’s first national Aboriginal and Torres Strait Islander antismoking campaign, launched in March 2011.39
Strengths and limitations
This is the first broadly representative survey of knowledge and health risk beliefs about smoking among Aboriginal and Torres Strait Islander peoples. The survey design made it feasible to interview a large number of people and to explore variation within our sample.
However, use of closed-ended questions may have led to overestimation of knowledge,40,41 which was assessed for a limited number of general health consequences of smoking. Knowledge may also have been overestimated if participants responded “yes” without fully scrutinising each question or because they did not want to appear uninformed. However, variation in the proportion of respondents who showed uncertainty in response to each item is evidence against this being systematic. Repeating the analyses with the “no” response as the dependent variable found the same general pattern of results (reversed). This increased our confidence in the validity of these outcomes, but did show that respondents from the most remote and disadvantaged areas were less likely to respond “don’t know”, consistent with biases to acquiesce or provide socially desirable responses in these areas. Some of the differences found, particularly area-level ones, may be due to social desirability biases, which are thought to be moderated by culture.42 Although face-to-face interviews can increase perceived pressure to provide socially acceptable responses, we attempted to reduce any such effects by engaging local interviewers, to minimise the social distance between the interviewer and participant.42
The questions used to assess health worry and risk minimisation showed good face validity, but have not been previously used to investigate these constructs with Aboriginal and Torres Strait Islander people. While these results paint a broad, representative picture of general health knowledge, concern and influence on quitting among Aboriginal and Torres Strait Islander people, more detailed assessments of knowledge may identify other gaps to target in future health information campaigns.
In conclusion, this national study found that lack of basic knowledge about the health consequences of smoking is not an important barrier to wanting and attempting to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages in ways that encompass the health of others is likely to contribute to goal setting and prioritisation of quitting.
1 Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander peoples*
|
Survey question and response |
Daily smokers (n = 1392) |
Non-daily smokers (n = 251) |
Ex-smokers (n = 311) |
Never-smokers (n = 568) |
|||||||||||
|
|
|||||||||||||||
|
Knowledge of direct health effects of smoking |
|||||||||||||||
|
Does smoking cause lung cancer? |
|||||||||||||||
|
Yes |
94% (1305) |
96% (242) |
96% (298) |
99% (560) |
|||||||||||
|
No |
2% (34) |
1% (3) |
2% (5) |
1% (4) |
|||||||||||
|
Don’t know |
3% (45) |
2% (6) |
2% (7) |
1% (4) |
|||||||||||
|
Does smoking cause heart disease? |
|||||||||||||||
|
Yes |
89% (1234) |
92% (231) |
92% (286) |
93% (526) |
|||||||||||
|
No |
4% (50) |
2% (6) |
4% (11) |
2% (13) |
|||||||||||
|
Don’t know |
7% (101) |
6% (14) |
4% (13) |
5% (29) |
|||||||||||
|
Does smoking make diabetes worse? |
|||||||||||||||
|
Yes |
68% (945) |
78% (197) |
71% (220) |
77% (435) |
|||||||||||
|
No |
7% (102) |
6% (15) |
5% (16) |
5% (28) |
|||||||||||
|
Don’t know |
24% (338) |
16% (39) |
24% (74) |
18% (105) |
|||||||||||
|
Does smoking cause low birthweight? |
|||||||||||||||
|
Yes |
82% (1131) |
87% (218) |
84% (261) |
88% (499) |
|||||||||||
|
No |
5% (75) |
3% (7) |
5% (15) |
2% (9) |
|||||||||||
|
Don’t know |
13% (179) |
10% (25) |
11% (33) |
11% (60) |
|||||||||||
|
Correct response to all four questions on direct effects of smoking |
59% (822) |
72% (181) |
61% (190) |
71% (403) |
|||||||||||
|
Knowledge of health effects of second-hand smoke |
|||||||||||||||
|
Does smoking cause asthma in children from second-hand smoke? |
|||||||||||||||
|
Yes |
91% (1265) |
94% (235) |
95% (293) |
94% (535) |
|||||||||||
|
No |
3% (38) |
2% (6) |
2% (7) |
1% (6) |
|||||||||||
|
Don’t know |
6% (82) |
4% (10) |
3% (10) |
5% (27) |
|||||||||||
|
Cigarette smoke is dangerous to non-smokers |
|||||||||||||||
|
Agree or strongly agree |
90% (1251) |
95% (238) |
95% (295) |
96% (546) |
|||||||||||
|
Neutral or don’t know |
7% (92) |
3% (7) |
2% (7) |
2% (14) |
|||||||||||
|
Disagree or strongly disagree |
3% (40) |
2% (6) |
2% (7) |
1% (8) |
|||||||||||
|
Cigarette smoke is dangerous to children |
|||||||||||||||
|
Agree or strongly agree |
95% (1317) |
98% (245) |
99% (306) |
99% (560) |
|||||||||||
|
Neutral or don’t know |
4% (52) |
2% (4) |
1% (2) |
1% (6) |
|||||||||||
|
Disagree or strongly disagree |
1% (14) |
1% (2) |
0 (1) |
0 (2) |
|||||||||||
|
Correct response to all three questions on harms of second-hand smoke |
85% (1173) |
90% (227) |
91% (282) |
91% (518) |
|||||||||||
|
Health risk beliefs |
|||||||||||||||
|
Smoking is not very risky when you think about all the things that people do |
|||||||||||||||
|
Agree or strongly agree |
44% (605) |
50% (126) |
— |
— |
|||||||||||
|
Neutral or don’t know |
18% (243) |
16% (39) |
— |
— |
|||||||||||
|
Disagree or strongly disagree |
39% (535) |
34% (86) |
— |
— |
|||||||||||
|
How worried are you that smoking will damage your health in the future? |
|||||||||||||||
|
Very worried |
36% (498) |
27% (68) |
— |
— |
|||||||||||
|
A little or moderately worried |
54% (735) |
63% (156) |
— |
— |
|||||||||||
|
Not at all worried |
10% (138) |
10% (24) |
— |
— |
|||||||||||
|
|
|||||||||||||||
|
* Results are based on the baseline sample (n = 2522) of the Talking About The Smokes project and are presented as % (frequency). Refused responses are excluded. |
|||||||||||||||
2 Association of knowledge and health risk beliefs with wanting and attempting to quit in a national sample of Aboriginal and Torres Strait Islander smokers*
|
Want to quit |
Attempted to quit in the past year |
||||||||||||||
|
Knowledge and health risk beliefs |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
% (frequency)† |
Adjusted OR (95% CI)‡ |
P§ |
|||||||||
|
|
|||||||||||||||
|
Knowledge about direct effects of smoking |
|||||||||||||||
|
Fewer than all four questions correct |
66% (395) |
1.0 |
0.16 |
50% (312) |
1.0 |
0.67 |
|||||||||
|
All four questions correct |
72% (686) |
1.21 (0.93–1.57) |
49% (482) |
0.95 (0.77–1.18) |
|||||||||||
|
Knowledge about harms of second-hand smoke |
|||||||||||||||
|
Fewer than all three questions correct |
46% (101) |
1.0 |
< 0.001 |
36% (83) |
< 0.001 |
||||||||||
|
All three questions correct |
74% (981) |
3.26 (2.25–4.70) |
52% (710) |
1.89 (1.38–2.57) |
|||||||||||
|
Risk-minimising beliefs |
|||||||||||||||
|
Don’t know or disagree (neutral) |
72% (622) |
1.0 |
0.21 |
50% (440) |
1.0 |
0.79 |
|||||||||
|
Agree |
67% (461) |
0.83 (0.62–1.11) |
49% (353) |
0.97 (0.78–1.21) |
|||||||||||
|
Health worry |
|||||||||||||||
|
Not at all or moderately worried |
59% (576) |
1.0 |
< 0.001 |
43% (450) |
1.0 |
< 0.001 |
|||||||||
|
Very worried |
90% (500) |
6.17 (4.40–8.66) |
60% (338) |
2.14 (1.68–2.73) |
|||||||||||
|
|
|||||||||||||||
|
OR = odds ratio. * Results are based on the baseline sample of current smokers (n = 1643) in the Talking About The Smokes project. † Percentages and frequencies exclude refused responses (for all variables) and “don’t know” responses (with the exception of knowledge questions, where “don’t know” is coded as incorrect). ‡ ORs are adjusted for daily smoking status and key sociodemographic variables (age, sex, identification as Aboriginal and/or Torres Strait Islander, labour force status, highest level of education, remoteness and area-level disadvantage). § P values are reported for overall variable significance, using adjusted Wald tests. |
|||||||||||||||
Dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers
In 1988, the United States Surgeon General concluded that nicotine is the drug in tobacco that causes dependence on smoking.1 The nicotine that is delivered to the brain when smoking interacts with the habits and sensory stimuli associated with smoking to reinforce the behaviour.2 Genetic factors also influence the biological processes of nicotine delivery, metabolism and dependence.2
Clinicians and scientists have sought indicators to predict the success or failure of quit attempts, beyond indicators of motivation. The best such measure is the Heaviness of Smoking Index (HSI),3 or at least one of its two component items: cigarettes per day (CPD) and the time to first cigarette (TTFC) after waking.4,5 These two items are a subset of the six items in the Fagerström Test for Nicotine Dependence.6 There is also evidence that strong cravings (both before and after quitting) and shorter periods of abstinence on past attempts may independently predict failure of quit attempts.7–9 Identifying smokers who are most likely to have difficulty quitting is important in determining who might benefit from medications to assist cessation.
The age-standardised prevalence of smoking is 2.6 times higher among Aboriginal and Torres Strait Islander people as among other Australians.10 While both smoking prevalence and smoking intensity (based on self-reported CPD) are falling among the Aboriginal and Torres Strait Islander population, measures of dependence may differently predict which smokers will have the most difficulty quitting in this high-prevalence population where smoking is more normalised.10,11 Two small research reports have suggested that over-reliance on strategies that use stop-smoking medications may not be appropriate in this population, as nicotine dependence may be lower than in other populations.12,13 One of these studies found only low per capita consumption of cigarettes in remote Aboriginal communities,12 and the other found that only a small proportion of a sample of pregnant Aboriginal and Torres Strait Islander women who smoked were highly dependent.13
Here, we use a large national study of Aboriginal and Torres Strait Islander smokers to examine different indicators of dependence in this population and their association with sustained quit attempts, and to make comparisons with a national sample of Australian smokers.
Methods
The Talking About The Smokes (TATS) project surveyed 1392 Aboriginal and Torres Strait Islander daily smokers using a quota sampling design in the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait, and has been described elsewhere.14,15 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or ex-smokers who had quit ≤ 12 months before, and 25 non-smokers, with equal numbers of women and men and of those aged 18–34 and ≥ 35 years. In four major-city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged less than 18 years, not usual residents of the area, staff of the ACCHS, or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.
Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. The baseline sample closely matched the national distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.14
The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.16 TATS project results were compared with those for 1010 daily smokers surveyed in Wave 8.5 of the Australian ITC Project between September 2011 and February 2012. That survey was completed by random digit telephone dialling or on the internet, and included smokers contacted for the first time and those who were recontacted after completing surveys in previous waves.
We asked questions about daily smokers’ usual smoking behaviour and variations in tobacco consumption, how easy it would be to not smoke, difficulties during their most recent quit attempt (eg, strong cravings, being around others who smoke), the duration of their longest quit attempt (to assess if any attempt had been sustained for at least 1 month) and sociodemographic factors. The questions are described in detail in Appendix 1.
The HSI was coded 0 to 6 based on the sum of the responses to the two questions about CPD and TTFC. These items were each coded as 0 (0–10 CPD; TTFC, ≥ 61 min), 1 (11–20 CPD; TTFC, 31–60 min), 2 (21–30 CPD; TTFC, 6–30 min) or 3 (≥ 31 CPD; TTFC, ≤ 5 min).3 We categorised HSI as low (0–1), moderate (2–3) or high (4–6).17,18 We also assessed the three criteria for dependence given in the Royal Australian College of General Practitioners (RACGP) cessation guidelines: TTFC ≤ 30 min, > 10 CPD, and withdrawal symptoms on previous quit attempts (defined in our sample as strong cravings during the most recent quit attempt).2
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, |
|||||||||||||
|
|
|||||||||||||||
|
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, |
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.
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.
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, |
Non-daily smokers, |
Ex-smokers, |
Never-smokers, |
|||||||||||
|
|
|||||||||||||||
|
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. |
|||||||||||||||
Research methods of Talking About The Smokes: an International Tobacco Control Policy Evaluation Project study with Aboriginal and Torres Strait Islander Australians
Australia is a world leader in tobacco control and in reducing its national smoking prevalence. However, 42% of Aboriginal and Torres Strait Islander Australians aged 15 years or older were daily smokers in 2012–2013 — 2.6 times the age-standardised prevalence among other Australians.1 Tobacco smoking was responsible for 20% of deaths and 12% of the total burden of disease in the Aboriginal and Torres Strait Islander population, and 17% of the health gap with other Australians in 2003.2,3
In response, community and government attention to Aboriginal and Torres Strait Islander tobacco control has increased in recent years, including increased government funding.4 It is important to understand what is assisting Aboriginal and Torres Strait Islander smokers to quit, both to evaluate the impact of current tobacco control efforts and to identify new strategies.
The International Tobacco Control Policy Evaluation Project (ITC Project) was established in 2002 to assess the effectiveness of national policy provisions in the World Health Organization Framework Convention on Tobacco Control.5,6 ITC Project studies have been undertaken in more than 20 countries, following up nationally representative cohorts of smokers, asking questions about smoking attitudes, behaviour and exposure to different tobacco control policies and activities. Additional smokers are recruited in subsequent survey waves to replenish the sample, replacing those lost to follow-up. The survey questions are based on a conceptual model that describes the causal pathways from policies to public health impact.6 This allows assessment of the impact of policies on behaviour and attitudes along the theorised causal pathway, and the investigation of how these impacts are moderated by other factors, such as sociodemographic factors, dependence and smoking history.
These key elements of the ITC Project (longitudinal design, comparisons between groups and countries exposed to different policies, and the conceptual model) have led to it being accepted as the most rigorous method of evaluating national tobacco control policies. They have now been used and adapted by those researching alcohol policy.7,8
Here, we describe the research methods used in the Talking About The Smokes (TATS) project, the first ITC Project study to sample only a high smoking prevalence subpopulation within a country; in this case, Aboriginal and Torres Strait Islander peoples. Like other studies of the ITC Project, it will answer research questions about the impact of tobacco control policies and activities along the theorised causal pathway to quitting, and compare findings with other ITC Project studies, especially the broader Australian surveys. We also compare the baseline community sample with a national household survey of Aboriginal and Torres Strait Islander peoples.
Methods
Design features
The TATS project is a collaboration between research institutions and Aboriginal community-controlled health services (ACCHSs) and their state and national representative bodies. These partnerships and project governance are described elsewhere in this supplement.9 Aboriginal organisations and Aboriginal and Torres Strait Islander people have been involved in all stages of the research project: design, data collection, analysis and research translation.
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.
Other Australian ITC Project surveys have been completed by random telephone survey, with an option to complete recontact surveys on the internet since 2008.10 In contrast, we chose to conduct face-to-face surveys, as telephone ownership is incomplete in the Aboriginal and Torres Strait Islander population.11 More importantly, past experiences have led to considerable distrust of research among the Aboriginal and Torres Strait Islander community, and we decided that the necessary respectful relationships to overcome this distrust were more likely to be created face to face.12,13
In addition to the surveys of community members, each ACCHS completed a single policy monitoring survey describing key tobacco control policies at each survey wave, and all staff of the ACCHSs were invited to complete an abbreviated version of the main community survey.
Sampling of clusters (ACCHSs)
Truly random probabilistic sampling was impractical as Aboriginal and Torres Strait Islander people account for only 3% of the total Australian population.14 We used a quota sampling design, based on meaningful clusters: the communities served by ACCHSs (and a community in the Torres Strait). Involving ACCHSs built local trust, facilitated local use of results and employment of local staff, and enabled us to examine differences between policies and practices of ACCHSs. We invited all 150 member services of the National Aboriginal Community Controlled Health Organisation that provided comprehensive primary health care to participate, excluding smaller member organisations that provided more limited services, such as aged care or drug and alcohol rehabilitation. We also included a cluster in the Torres Strait where 15% of Torres Strait Islanders live, but where there is no ACCHS.15
We aimed to collect data from 40 clusters or sites reflecting the geographic distribution of the Aboriginal and Torres Strait Islander population. Target numbers of clusters for each of three remoteness categories (major cities, inner and outer regional, remote and very remote) were calculated for each jurisdiction using 2006 Census data.15 As there were smaller numbers of eligible ACCHSs in the major cities, each eligible major-city ACCHS was invited to recruit double the standard cluster quota of participants, as was the Torres Strait community. Recruitment of sites occurred over 18 months.
Forty quotas (including double quotas from four major-city sites and the Torres Strait community) were recruited from 35 clusters (Box 1). This closely matched the national geographic distribution of the population: 28% of the 40 quotas were from major cities, 45% from regional areas, and 28% from remote and very remote areas, compared with 32%, 44% and 25%, respectively, of the total estimated resident Aboriginal and Torres Strait Islander population on 30 June 2006. For the three states with the largest Aboriginal and Torres Strait Islander population, 28% of quotas were from New South Wales, 30% from Queensland and 15% from Western Australia, compared with 29%, 28% and 15%, respectively, of the population.15
Sampling within each cluster (ACCHS)
In the baseline survey (Wave 1) at each site, we aimed to survey samples of 50 smokers or recent ex-smokers (who had quit ≤ 12 months previously, to examine relapse) and 25 non-smokers (never-smokers and ex-smokers who had quit > 12 months previously) from the Aboriginal and Torres Strait Islander community, with equal numbers of men and women and in each of two age groups (18–34 and ≥ 35 years). The age cut-point was chosen because the median age of an Aboriginal or Torres Strait Islander smoker aged ≥ 18 years in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) was 34 years. People were excluded if they were: non-Indigenous, aged less than 18 years, acutely unwell, not usual residents of the area, staff members of the ACCHS, unable to complete the survey in English (if there was no interpreter available), or if the quota for the relevant age–sex–smoking category had been filled.
In each location, we negotiated with the ACCHS to decide on the method of sampling. While we explained to local research assistants (RAs) the need to collect a representative sample of their community (eg, not just all the people from a few adjacent households), sampling was non-random. Methods included sampling of known Aboriginal or Torres Strait Islander households, opportunistic sampling at Aboriginal community events and organisations (including the ACCHS), and snowballed invitations to people whom others suggested might be interested. The project compensated participants with a $20 local business voucher on completion of the survey, except in nine sites where the ACCHS supplemented this to $30 or $50, reflecting local perceptions of fair compensation.
In the follow-up survey (Wave 2) at each site, we focused on recontacting the smokers and recent ex-smokers who had completed the Wave 1 survey. As we did not expect to recontact them all, we replenished our sample with smokers who had not completed Wave 1 (to a maximum of 50, or 100 if a double quota, recontacted or replenished in each location), using the same sampling methods as in Wave 1. Participant compensation was increased to facilitate follow-up, ranging from $30 to $50. We did not recontact non-smokers from Wave 1, nor survey a new community sample of non-smokers. All staff at each ACCHS were invited at each wave to complete the short staff survey.
Sample size
Our target sample size in Wave 1 was 2000 smokers or recent ex-smokers (of whom we expected to recontact 1000 in Wave 2) and 1000 non-smokers. These sample sizes were not primarily based on power calculations but on available resources and the experience of other ITC Project studies that suggested 2000 baseline and 1000 recontacted smokers or recent ex-smokers would provide sufficient power for meaningful estimates. The sample size of non-smokers was smaller, to concentrate resources on sampling smokers and recent ex-smokers. Rather than simply excluding non-smokers at screening, we took the opportunity to ask fewer questions to examine differences between them and smokers.
Questionnaire development
Three surveys were developed for each survey wave: (1) the main survey for smokers and non-smokers in each community; (2) the ACCHS staff survey; and (3) the policy monitoring survey for each ACCHS. The final versions of all Wave 1 questionnaires were produced by a collaborative effort based on email exchanges, teleconferences and five face-to-face meetings of the research team, the Project Reference Group and project staff.9
The main community survey included sections on smoking behaviour, smoking in the participant’s social network, second-hand smoke, quitting history, tobacco brands and prices, use of smokeless tobacco, knowledge about health effects, attitudes, advertising and promotion (including health warnings), medications to stop smoking and cessation support. It was based on core questions from ITC Project surveys, to enable comparisons with other studies. Other questions reflecting specific concerns in this setting were added. For example, the smokeless tobacco section included questions about chewing pituri or native tobaccos as well as store-bought tobacco, and the second-hand smoke section included specific questions about smoking bans at ACCHSs. The wording of some questions was modified to better reflect Aboriginal and Torres Strait Islander colloquial speech.
The main survey was piloted with 24 participants in Darwin in Wave 1. Our first site (with 48 participants) was treated as a quasi-pilot in Wave 1, trialling all aspects of the project, which were reviewed before the second site commenced. This led to us dropping some questions and revising the wording of others (mainly abbreviating questions and their preambles). As these changes were modest, data from this first site were included in the total sample.
The staff survey used a small selection of questions from the main community survey, supplemented by additional questions about staff roles at the ACCHS. The policy monitoring survey included questions about the ACCHS and the community it served, tobacco control activities run by the ACCHS and tobacco control policies (especially smoking bans) at the ACCHS.
Wave 2 survey instruments were closely based on Wave 1 and were not separately piloted. In Wave 2, some Wave 1 questions were dropped after review, and new questions were added to reflect changes in the policy environment. The main survey was restructured by referring to responses in Wave 1, to accommodate people being recontacted, and did not repeat questions to which the answers were unlikely to have changed.
Copies of all the surveys are available at http://www.itcproject.org/countries/australia/tats.
Data collection methods
Wave 1 surveys were conducted between April 2012 and October 2013, and Wave 2 surveys between July 2013 and August 2014. The project funded participating ACCHSs to employ RAs for 6 weeks of data collection for each wave; however, many sites chose to continue recruitment longer in order to meet target numbers. In the Torres Strait community, the project funded the Queensland Aboriginal and Islander Health Council to employ RAs. Of the 101 local RAs (72 in Wave 1 and 57 in Wave 2, including 28 in both), all except seven were Aboriginal or Torres Strait Islander people. RAs received training on site from project staff for 1–3 days before each wave, followed by ongoing telephone and electronic support.
The main community surveys were conducted face to face, with results recorded on a computer tablet and data uploaded to a secure server. Depending on their answers, smokers generally completed the survey (including the consent process) in just under an hour, and non-smokers in 40 minutes, although some participants took much longer because of additional (unrecorded) “yarning” about the issues raised. Anonymous staff surveys were self-administered on paper or online and took 5–10 minutes to complete. The policy monitoring survey was completed on paper with key informants from the ACCHS at each wave.
Statistical methods
In this article, we compare baseline frequencies and percentages (by smoking status) for questions in the main community survey with unweighted and weighted results from the 2008 NATSISS. The NATSISS was a national, stratified, multistage, random, face-to-face household survey of 7823 Aboriginal and Torres Strait Islander adults and 5484 children conducted by the Australian Bureau of Statistics (ABS) from August 2008 to April 2009.16 Visitors and those not in private dwellings were excluded. We analysed these data using the ABS’s Remote Access Data Laboratory, with replicate weights used to estimate random sampling error and confidence intervals, as previously described.17
Person weights were used to generalise results to the total Aboriginal and Torres Strait Islander population, based on the inverse of the probability of selection in the NATSISS calibrated to benchmarks based on combinations of age, sex, remoteness and state in the estimated resident population in private dwellings on 31 December 2008. The ABS adjusted these person weights further due to the high estimated 53% undercoverage, in particular for those selected not being contacted or not responding, and for Indigenous people not identifying themselves as Indigenous.16
For one item not available in the NATSISS (having seen a health professional in the past year), we made comparisons with the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), a similar ABS household survey of 5757 adults and 4682 children conducted from August 2004 to July 2005, using similar person and replicate weights.18 We also investigated the effect of the slightly different definitions of smoking status in our survey, the NATSISS and the Australian ITC Project surveys.
In other analyses of the baseline survey reported in this supplement, we mainly compared frequencies and percentages (by smoking status) for questions in the main community survey with weighted results from Australian ITC Project surveys — usually the most recent survey conducted by telephone or the internet from September 2011 to February 2012 (Wave 8.5, n = 1504). When appropriate (eg, if questions were not asked in the latest survey), we have made comparisons with earlier surveys.
As the Aboriginal and Torres Strait Islander population is much younger than the general Australian population, we weighted the Australian ITC Project results to the distribution of age (18–24, 25–34, 35–44, 45–54, ≥ 55 years), sex and smoking status (smoker, ex-smoker, never-smoker) in the total Aboriginal and Torres Strait Islander population in the 2008 NATSISS, analogous to direct standardised comparisons. We concentrated comparisons on daily smokers, due to slightly different definitions of smokers in each survey which meant that only daily and weekly smokers were directly comparable.
We examined associations between variables in our main community sample using either simple logistic regression or multiple logistic regression (adjusted for sociodemographic and other variables) to generate odds ratios and Wald tests. Stata 13 (StataCorp) survey [SVY] commands were used to adjust for the sampling design, using 35 site clusters and eight strata based on age (18–34 v ≥ 35 years), sex and smoking status (smokers and recent ex-smokers v non-smokers).19
Similar statistical methods were used to analyse results of the policy monitoring and staff surveys. However, given the different age and sex structure of Aboriginal and Torres Strait Islander staff at ACCHSs, staff responses have been weighted as above for comparisons with the community survey or the NATSISS.
As data from the follow-up survey (Wave 2) are not yet available and are not included in this supplement, we have not described the statistical methods for these longitudinal analyses.
Results
The Wave 1 survey sample included 2522 community members: 1643 smokers, 78 ex-smokers who quit ≤ 12 months previously, 233 ex-smokers who quit > 12 months previously, and 568 never-smokers. At the five sites with participation data available, a median of 9% of those approached by RAs refused to participate, with marked variation between sites. Only 37 participants were excluded because they were ineligible; a further 12 people did not complete the full survey but were retained in the final sample. Of the eligible smokers and recent ex-smokers, 75% (1295/1721) consented to be recontacted in Wave 2, and 49% (849/1721) were successfully recontacted and resurveyed.
The representativeness of the 645 staff surveyed is discussed elsewhere in this supplement, but as we were not able to determine the exact number of current staff in each ACCHS, we could not determine what proportion had been surveyed.20
Generalisability and comparison of our sample with other surveys
Our Wave 1 sample closely matched the distribution of the Aboriginal and Torres Strait Islander population in the weighted NATSISS by age, sex, jurisdiction and remoteness (Box 2). Similarly, most of our sample (89%) identified as Aboriginal, 5% as Torres Strait Islander, and 6% as both, compared with 91%, 6% and 3%, respectively, of Indigenous people aged ≥ 20 years in the 2011 Census.22
However, compared with the weighted NATSISS, our sample had higher proportions of participants who were from less disadvantaged areas, were unemployed, had completed Year 12 at school, and reported speaking an Indigenous language at home or being treated unfairly because they were Indigenous (Box 2). Among smokers only, a higher proportion had poor or fair self-reported health (Box 3). A higher proportion of smokers in our sample were non-daily smokers and, among the non-smokers, a higher proportion were never-smokers. However, similar proportions of smokers in our sample and the NATSISS reported having attempted to quit in the past year, and daily smokers reported similar numbers of cigarettes smoked per day (Box 3).
The unweighted NATSISS included smaller proportions of participants from the two jurisdictions with most Aboriginal and Torres Strait Islander people (New South Wales and Queensland), non-remote areas and the youngest age group (18–24 years) compared with the population benchmarks used for providing the weighted NATSISS estimates. Apart from these weighting variables, there were only small differences between the unweighted and weighted NATSISS estimates for the other common variables.
Discussion
The 2008 NATSISS and related Aboriginal and Torres Strait Islander health and social surveys conducted by the ABS are assumed to provide the most accurate available national estimates of the prevalence of key smoking-related and other health and social indicators. Unfortunately, access to detailed data from the most recent survey in this series, with its lower estimate of smoking prevalence, was not available at the time of writing.1 Sampling errors in the NATSISS are small and can be estimated due to the probabilistic sampling design. However, the ABS acknowledges that non-sampling errors due to the large level of undercoverage in the 2008 NATSISS may introduce bias, if, for example, the estimated 31% of Indigenous people screened in areas other than discrete Indigenous communities who did not identify as Indigenous were different from those who did identify and so could participate.16 Similarly, those excluded from the sample because they were not usual residents of private dwellings (eg, visitors and people in hostels, caravan parks, prisons or hospitals) may have responded differently to those who were included.
In contrast, it is not considered statistically acceptable to estimate sampling error in our non-probabilistic quota sample, and confidence intervals for prevalence estimates are not included. Probabilistic sampling was considered impractical in this instance, and accommodating local practical concerns in our sampling was part of building strong relationships with the local ACCHSs, RAs and communities.13 These relationships not only facilitated the use of local and national results by ACCHSs, but built local trust in the research, reducing non-sampling bias and facilitating follow-up. We felt people would be more comfortable talking with a known RA from the local community than with an outsider. In contrast, the NATSISS was administered by ABS interviewers, only accompanied by local Indigenous facilitators in discrete Indigenous communities “where possible”.16 This may explain the higher proportions of people in our sample who reported speaking an Indigenous language at home or being treated unfairly because they were Indigenous.
The distribution of some sociodemographic factors was different in the NATSISS and our sample: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas. As our sample purposefully oversampled smokers (and recent ex-smokers), we have not combined smokers and non-smokers and have avoided providing estimates for the total sample in this and other articles in the supplement, as smokers and non-smokers vary for many of the variables we examined.
Potential bias may have been introduced by using the local ACCHSs to access the community, as we would expect people with greater links to the health services to be sampled. However, similar proportions of participants in our sample reported seeing a health professional in the past year as for the narrower question about seeing a doctor in the NATSIHS. The poorer self-reported health among smokers in our sample than in the NATSISS may be due to bias by sampling through ACCHSs or by this question coming at the end of a long survey specifically about smoking rather than as part of a much broader social survey in the NATSISS. Nevertheless, Aboriginal and Torres Strait Islander people with connections to an ACCHS may be different to others who have limited links to their local ACCHS or who do not live near an ACCHS. However, most tobacco control activity specifically targeting Aboriginal and Torres Strait Islander peoples has been delivered through ACCHSs, so our sample is focused on those who are also the target of this activity.
It is uncertain what potential biases were introduced by the compensation provided, or the differences in compensation, but we expect these to be small.
Unlike either ABS or other ITC Project surveys, we based smoking status entirely on self-definition rather than using additional probing questions. Other ITC Project surveys excluded smokers who said they had smoked less than 100 cigarettes in their lifetime and those who smoked less than monthly, but when recontacted smokers then said they smoked less than monthly, they were asked to self-identify as either smokers or ex-smokers (and then treated accordingly). In the 2008 NATSISS, the question about 100 lifetime cigarettes was only used to distinguish between ex-smokers and never-smokers. In our sample, 33 smokers and 36 ex-smokers said they had not smoked 100 lifetime cigarettes, and 16 of the total sample answered “don’t know”. We are concerned that this question may be sometimes misinterpreted in this population. As our sample included 64 less-than-monthly smokers, in this supplement we have concentrated our comparisons with Australian ITC Project results on daily smokers rather than all smokers.
In summary, we found no evidence of large systematic bias in our sample and, with appropriate caution, we can compare our prevalence estimates, cross-sectional associations and longitudinal analyses with other surveys, and generalise our findings to the national Aboriginal and Torres Strait Islander population. We are most confident in the methodological strengths of the longitudinal design and future longitudinal analyses.7 More caution is needed in interpreting our prevalence estimates, but in spite of the methodological uncertainties of using a non-probabilistic sample, we believe this, like many other quota samples, is likely to give estimates similar to a probabilistic sample (which may be subject to different biases, as we have shown with the NATSISS).23
We do not report confidence intervals around our prevalence estimates, only report percentages of our sample to the nearest integer, and concentrate on large differences from other samples. Similarly, we have chosen not to present results at the state or territory level, in spite of policy interest, as for many jurisdictions the sample sizes were small and from a small number of clusters, and the results are not generalisable to the entire state or territory. Some caution is necessary in comparisons with Australian ITC Project results, as our survey was administered face to face, and Australian ITC Project surveys were conducted on the telephone or internet, which can influence how people respond to some questions.7
In conclusion, the TATS project provides a detailed and nationally representative description of Aboriginal and Torres Strait Islander smoking behaviour, attitudes, knowledge and exposure to tobacco control activities and policies and their association with quitting, and comparisons with other contexts. This information has the potential to transform the evidence base being used to inform policies and programs to reduce Aboriginal and Torres Strait Islander smoking and the preventable illness and suffering it causes.
1 Participating sites in the Talking About The Smokes project*
* There were three participating health services in Brisbane, and double quotas were recruited in Perth, Canberra, Newcastle, Wyong and the Torres Strait.
2 Comparison of sociodemographic characteristics of the baseline community sample in the Talking About The Smokes (TATS) project with the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS)*
|
Smokers† |
Non-smokers† |
||||||||||||||
|
TATS (n = 1643) |
NATSISS (n = 3612) |
TATS (n = 879) |
NATSISS (n = 3551) |
||||||||||||
|
Characteristic |
% (n) |
Unweighted, % (n) |
Weighted, % (95% CI) |
% (n) |
Unweighted, % (n) |
Weighted, % (95% CI) |
|||||||||
|
|
|||||||||||||||
|
Jurisdiction |
|||||||||||||||
|
New South Wales |
27% (441) |
15.1% (547) |
30.0% (27.9%–32.1%) |
27% (241) |
13.9% (494) |
28.8% (26.7%–30.9%) |
|||||||||
|
Victoria |
5% (82) |
17.0% (615) |
6.6% (6.0%–7.2%) |
6% (51) |
16.4% (581) |
6.7% (6.1%–7.2%) |
|||||||||
|
Queensland |
31% (517) |
15.2% (550) |
26.3% (24.4%–28.2%) |
32% (283) |
15.7% (556) |
28.6% (26.6%–30.7%) |
|||||||||
|
South Australia |
6% (94) |
10.0% (360) |
5.7% (5.1%–6.3%) |
5% (43) |
9.6% (340) |
5.4% (4.8%–6.0%) |
|||||||||
|
Western Australia |
12% (203) |
14.4% (521) |
12.8% (11.6%–14.1%) |
14% (124) |
14.8% (525) |
14.0% (12.8%–15.3%) |
|||||||||
|
Northern Territory |
11% (179) |
17.8% (643) |
14.3% (13.1%–15.6%) |
9% (75) |
16.2% (575) |
11.7% (10.5%–13.0%) |
|||||||||
|
Tasmania‡ |
3% (47) |
na |
na |
3% (26) |
na |
na |
|||||||||
|
Australian Capital Territory‡ |
5% (80) |
na |
na |
4% (36) |
na |
na |
|||||||||
|
Tasmania and ACT combined‡ |
8% (127) |
10.4% (376) |
4.3% (3.9%–4.8%) |
7% (62) |
13.5% (480) |
4.9% (4.4%–5.4%) |
|||||||||
|
Area-level disadvantage§ |
|||||||||||||||
|
1st quintile (most disadvantaged) |
39% (640) |
65.9% (2380) |
60.3% (55.2%–65.2%) |
32% (277) |
53.0% (1882) |
46.7% (41.5%–51.9%) |
|||||||||
|
2nd and 3rd quintiles |
42% (683) |
24.7% (891) |
28.2% (23.8%–33.1%) |
47% (409) |
31.5% (1117) |
36.8% (31.8%–42.2%) |
|||||||||
|
4th and 5th quintiles |
19% (320) |
9.4% (341) |
11.5% (8.9%–14.7%) |
22% (193) |
15.5% (552) |
16.5% (13.3%–20.3%) |
|||||||||
|
Remoteness |
|||||||||||||||
|
Non-remote |
77% (1258) |
63.4% (2399) |
71.8% (70.1%–73.5%) |
80% (700) |
69.1% (2789) |
78.0% (76.5%–79.3%) |
|||||||||
|
Remote |
23% (385) |
36.6% (1385) |
28.2% (26.5%–29.9%) |
20% (179) |
31.0% (1250) |
22.0% (20.7%–23.5%) |
|||||||||
|
Age (years) |
|||||||||||||||
|
18–24 |
21% (346) |
19.5% (703) |
24.7% (22.6%–26.9%) |
25% (219) |
16.6% (591) |
21.8% (20.0%–23.7%) |
|||||||||
|
25–34 |
27% (441) |
28.6% (1034) |
26.9% (25.4%–28.5%) |
22% (195) |
21.8% (775) |
21.2% (19.7%–22.7%) |
|||||||||
|
35–44 |
24% (400) |
24.5% (884) |
23.4% (21.8%–25.0%) |
17% (150) |
20.5% (729) |
20.5% (19.0%–22.2%) |
|||||||||
|
45–54 |
17% (274) |
15.9% (575) |
15.5% (14.1%–17.0%) |
17% (151) |
17.0% (605) |
16.7% (15.4%–18.2%) |
|||||||||
|
≥ 55 |
11% (182) |
11.5% (416) |
9.5% (8.4%–10.7%) |
19% (164) |
24.0% (851) |
19.8% (18.6%–21.0%) |
|||||||||
|
Sex |
|||||||||||||||
|
Female |
52% (848) |
55.3% (1998) |
50.1% (48.0%–52.1%) |
56% (488) |
58.8% (2088) |
55.3% (53.3%–57.3%) |
|||||||||
|
Male |
48% (795) |
44.7% (1614) |
49.9% (47.9%–52.0%) |
44% (391) |
41.2% (1463) |
44.7% (42.7%–46.7%) |
|||||||||
|
Labour force status |
|||||||||||||||
|
Employed |
35% (574) |
47.9% (1731) |
48.5% (45.8%–51.2%) |
48% (423) |
57.5% (2041) |
59.4% (56.3%–62.4%) |
|||||||||
|
Unemployed |
34% (565) |
11.8% (426) |
13.1% (11.3%–15.2%) |
22% (191) |
5.5% (195) |
6.1% (4.9%–7.6%) |
|||||||||
|
Not in labour force |
31% (502) |
40.3% (1455) |
38.3% (35.9%–40.8%) |
30% (265) |
37.0% (1315) |
34.5% (32.0%–37.1%) |
|||||||||
|
Highest education attained |
|||||||||||||||
|
Less than Year 12 |
52% (842) |
63.1% (2278) |
62.9% (59.9%–65.8%) |
40% (351) |
50.4% (1789) |
48.7% (45.7%–51.6%) |
|||||||||
|
Finished Year 12 |
27% (434) |
7.7% (278) |
9.4% (7.9%–11.2%) |
29% (253) |
11.8% (420) |
13.9% (12.2%–15.7%) |
|||||||||
|
Post-school qualification |
22% (351) |
29.2% (1056) |
27.7% (25.2%–30.3%) |
31% (269) |
37.8% (1342) |
37.5% (34.9%–40.2%) |
|||||||||
|
Housing tenure |
|||||||||||||||
|
Owns or purchasing home |
14% (230) |
18.9% (679) |
19.9% (17.3%–22.9%) |
23% (203) |
37.8% (1337) |
38.3% (35.4%–41.3%) |
|||||||||
|
Renter or other |
86% (1400) |
81.1% (2907) |
80.1% (77.1%–82.7%) |
77% (672) |
62.2% (2196) |
61.7% (58.7%–64.6%) |
|||||||||
|
Speaks an Indigenous language at home |
|||||||||||||||
|
No |
78% (1262) |
85.3% (3082) |
86.8% (84.3%–88.9%) |
80% (694) |
86.9% (3085) |
88.7% (86.8%–90.3%) |
|||||||||
|
Yes |
22% (365) |
14.7% (530) |
13.2% (11.1%–15.7%) |
20% (178) |
13.1% (466) |
11.3% (9.7%–13.2%) |
|||||||||
|
Treated unfairly because Indigenous in past year |
|||||||||||||||
|
No |
43% (690) |
68.6% (2476) |
69.1% (66.3%–71.8%) |
51% (443) |
75.5% (2680) |
75.2% (72.6%–77.6%) |
|||||||||
|
Yes |
57% (908) |
31.5% (1136) |
30.9% (28.2%–33.7%) |
49% (420) |
24.5% (871) |
24.8% (22.4%–27.4%) |
|||||||||
|
|
|||||||||||||||
|
na = not available. * Percentages exclude those who did not answer or answered “don’t know”. † Data for smokers include current smokers only, and data for non-smokers include all ex-smokers and never-smokers. ‡ The Australian Bureau of Statistics (ABS) only provides researchers with combined NATSISS results for Tasmania and the ACT. § The TATS project used postcodes and concordance tables for the ABS 2011 Socio-Economic Indexes for Areas (SEIFA) Index of Relative Socio-economic Disadvantage (IRSD).21 The NATSISS used the 2006 SEIFA IRSD directly from Census Collection Districts. |
|||||||||||||||
3 Comparison of smoking and health status of the baseline community sample in the Talking About The Smokes (TATS) project with the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS)*
|
Smokers† |
Non-smokers† |
||||||||||||||
|
TATS (n = 1643) |
NATSISS (n = 3612) |
TATS (n = 879) |
NATSISS (n = 3551) |
||||||||||||
|
Characteristic |
% (n) |
Unweighted, % (n) |
Weighted, % (95% CI) |
% (n) |
Unweighted, % (n) |
Weighted, % (95% CI) |
|||||||||
|
|
|||||||||||||||
|
Smoking status |
|||||||||||||||
|
Daily smoker |
85% (1392) |
95.2% (3439) |
95.7% (94.5%–96.6%) |
— |
— |
— |
|||||||||
|
Non-daily smoker |
15% (251) |
4.8% (173) |
4.3% (3.4%–5.5%) |
— |
— |
— |
|||||||||
|
Ex-smoker |
— |
— |
— |
35% (311) |
43.8% (1554) |
42.6% (39.9%–45.4%) |
|||||||||
|
Never-smoker |
— |
— |
— |
65% (568) |
56.2% (1997) |
57.4% (54.6%–60.1%) |
|||||||||
|
Cigarettes per day (daily smokers only) |
|||||||||||||||
|
1–10 |
40% (547) |
43.9% (1502) |
43.9% (41.0%–46.7%) |
— |
— |
— |
|||||||||
|
11–20 |
39% (528) |
34.1% (1164) |
34.1% (31.5%–36.7%) |
— |
— |
— |
|||||||||
|
21–30 |
18% (242) |
17.5% (598) |
17.0% (15.1%–18.9%) |
— |
— |
— |
|||||||||
|
≥ 31 |
4% (54) |
4.5% (155) |
5.0% (3.7%–6.3%) |
— |
— |
— |
|||||||||
|
Quit attempt in past year |
|||||||||||||||
|
No |
51% (813) |
56.1% (1990) |
55.3% (52.6%–58%) |
— |
— |
— |
|||||||||
|
Yes |
49% (796) |
43.9% (1560) |
44.7% (42%–47.4%) |
— |
— |
— |
|||||||||
|
Self-reported health status |
|||||||||||||||
|
Poor or fair |
45% (735) |
27.3% (985) |
26.2% (23.7%–28.8%) |
24% (209) |
23.7% (842) |
22.6% (20.3%–25.0%) |
|||||||||
|
Good |
40% (653) |
35.7% (1290) |
36.3% (33.6%–39.2%) |
43% (367) |
32.8% (1164) |
32.4% (29.8%–35.1%) |
|||||||||
|
Excellent or very good |
15% (238) |
37.0% (1337) |
37.5% (35.1%–40.0%) |
33% (281) |
43.5% (1545) |
45.0% (42.0%–48.0%) |
|||||||||
|
Seen by doctor/health professional in past year‡ |
|||||||||||||||
|
Yes |
75% (1225) |
77.2% (2308) |
75.2% (72.5%–77.6%) |
85% (741) |
83.0% (2251) |
82.0% (79.6%–84.1%) |
|||||||||
|
No |
25% (399) |
22.8% (683) |
24.8% (22.4%–27.5%) |
15% (134) |
17.0% (460) |
18.0% (15.9%–20.4%) |
|||||||||
|
|
|||||||||||||||
|
* Percentages exclude those who did not answer or answered “don’t know”. † Data for smokers include current smokers only, and data for non-smokers include all ex-smokers and never-smokers. ‡ As this question was not asked in the NATSISS, comparison is with the 2004–05 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS). The TATS project question asked whether the participant had seen a health worker, doctor, nurse or other health professional in the past year. The NATSIHS question asked only about the time since the participant had last consulted a doctor. |
|||||||||||||||