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Preference: Statistics, epidemiology and research design

1138

Waste not, want not – ethics, stewardship and patient care

By Dr Michael Gannon

When it comes to managing health care resources, doctors must balance their primary ethical obligation to care for the patient with their secondary obligation to use health care resources wisely.

At times, these obligations may conflict – but focussing on stewardship allows doctors to find an equitable and realistic balance between the needs of the patient and the need for the wider community to keep health care affordable.

The essence of stewardship is avoiding waste – it is not about denying care based on scarcity of resources, otherwise known as rationing.

How do we become effective stewards of health care and avoid waste without being seen to ration care?

How do we deal with health care administrators, third party payers and governments who place unreasonable constraints on our ability to make treatment recommendations based on our patients’ health care needs, rather than the cost of care?

How do we manage patients (and family members) who make unreasonable health care demands, requesting treatments that are simply ineffective or inappropriate for their health care needs?

And what about the ever present fear of litigation – isn’t ‘defensive medicine’ the best way to practice?

At this year’s AMA National Conference, I chaired a policy session on stewardship, Waste Not, Want Not: Ethics, Stewardship and Patient Care.

The purpose was to assist doctors to become better stewards of our health care resources through learning how to:

  • identify the medico-legal challenges to effective stewardship;
  • communicate with patients about resource use; and
  • participate in initiatives that identify and discourage ineffective care at the institutional level, as well as in the wider community.

The session’s presenters, Dr Ian Scott, Dr Sara Bird and Dr Lynn Weekes, were truly engaging.

Dr Scott, Director of the Department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital in Brisbane, outlined 10 clinician-led strategies to maximise value in Australian health care.

Dr Bird, Manager of the Medico-Legal and Advisory Services of MDA National, provided a medico-legal perspective on stewardship in relation to the practice of defensive medicine.

Dr Weekes, the CEO of NPSMedicineWise, presented the ChoosingWiselyAustralia campaign, whose goal is to enhance quality care by reducing unnecessary care.

We are truly indebted to our presenters and appreciate the time they took to engage with our delegates during a lively question and answer session following their presentations.

The AMA’s job now is to develop a policy on ethics and stewardship to assist our advocacy.

We want to ensure there is a culture of stewardship within the medical profession.

This clearly begins at medical school and continues throughout a doctor’s career with continuing professional development.

Doctors need to be informed of the cost of treatments and procedures, and be guided in making responsible treatment recommendations that balance efficiency with the primacy of patient care.

We also need to ensure that any system-level initiatives to reduce wastage involve the profession, and do not compromise our professional judgement and clinical independence to act in the best interests of individual patients and advocate for the wider public health. 

I strongly encourage all members to visit the AMA website and view the presentations, along with the question and answer session from the policy discussion session Waste Not, Want Not: Ethics, Stewardship and Patient Care. They can be viewed at media/ama-national-conference-30-may-2015-session-2.

 

Signs not good for flu season

Parts of Australia are on track for their worst flu seasons in years, with infection rates in the north and south of the country already far ahead of last year.

So far this year, 9213 laboratory-confirmed cases of the disease have been notified to health authorities, compared with 6225 cases at the same point last year.

Queensland (2757 confirmed cases) and South Australia (1742 cases) have, proportionately, been the hardest hit, while the rate of infections in both New South Wales and Victoria have so far been relatively low.

But the slow start to the flue season in the two most populace states is little cause for complacency.

The Influenza Specialist Group warned that the flu season had not yet begun in earnest, and was likely to develop in the next four weeks.

Evidence from last year suggests there is every reason to be concerned.

While there were less than laboratory-confirmed cases by the end of May 2014, that number quickly accelerated as flu season hit, and by year’s end there were 67,854 confirmed cases nationwide, almost double the long-term average of 34,523.

Promisingly, early figures suggest vaccinations are helping to reduce the number and severity of infections.

The pilot Flu Tracking surveillance system, a joint University of Newcastle, Hunter New England Area Health Service and Hunter Medical Research initiative that collects data from a weekly online survey, has so far identified only low levels of influenza infection.

But it found that 3.4 per cent of those not vaccinated against the flu suffered fevers and coughs, and 2.1 per cent had to take time off work, while among those vaccinated, 2.7 per cent had coughs and fevers and 1.6 per cent reported having to take sick leave.

The results underline calls from AMA Vice President Dr Stephen Parnis for people, particularly elderly and vulnerable patients and health professionals, to make sure they are vaccinated against the flu.

Dr Parnis said it was important for doctors, nurses and other health workers to get the flu vaccine, for the sake of their own health as well as that of their patients.

The National Seasonal Influenza Immunisation Program started late this year, the delay caused by a rush to include vaccines covering two new strains of the virus one of which caused havoc in the northern hemisphere.

In the US alone, around 100 children were reported to have died from the flu during the northern flu season, and there was also widespread illness among the elderly.

For the first time under the national immunisation program, Australians have access to single-dose vaccines covering the four most common flu viruses, including three quadrivalent formulations.

The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.

But Chief Medical Officer Professor Chris Baggoley has been forced to issue an urgent warning to health professionals after it was revealed that at least nine young children had been injected with the Fluvax vaccine despite explicit directions from the Government and the manufacturer that it was potentially dangerous to use on those younger than five years.

The ban has been in place since several young children given Fluvax in 2012 suffered fevers and febrile convulsions, and part of the reason for the delay in starting this year’s flu immunisation program was to ensure that suitable vaccines were available for the very young.

Adrian Rollins

 

[Case Report] Hypoplastic left heart in the 6500-year-old Detmold Child

Palaeopathology, the scientific study of ancient diseases, has evolved in recent decades into a modern scientific area and become part of medical research. Virtual autopsies, like those undertaken in modern forensic institutes, can be done on ancient mummies to examine injuries, genetic defects, acquired diseases, and determine sex.1

PM dodges evidence to take tilt at windmills

Prime Minister Tony Abbott has linked wind farms to adverse health effects despite the lack of scientific evidence to back the claim.

Declaring that he would like to see the number of wind generators around the country cut, Mr Abbott told Sydney broadcaster Alan Jones that he understood the concerns of those who complained inaudible low frequency sound generated by wind farms caused headaches, nausea, sleeplessness and other health problems.

“I do take your point about the potential health impact of these things,” the Prime Minister said. “When I have been up close to these wind farms, not only are they visually awful, but they make a lot of noise.”

Mr Abbott made his comments just days after acoustic experts told a Senate inquiry there was no evidence that people were physically affected by low-frequency sound like that emitted by wind turbines.

Members of the Association of Australian Acoustic Consultants told the Senate inquiry into wind turbines on 10 June that several studies detected no perceivable physical reaction to so-called infrasound.

“We can measure the level of infrasound in a windfarm, and we know what that level is, and we can measure it inside rooms, and that has been done on a number of occasions,” Chair of the AAAC’s windfarm subcommittee, Chris Turnbull, said.

“If we replicate that level at the same character, and the same frequencies, that person is essentially exposed to the same level of infrasound in terms of character and level [as a windfarm],” he said. “To date, all of the studies have suggested that there is no reaction to that level of infrasound.”

The testimony came weeks after the National Health and Medical Research Council released the results of a three-year investigation involving the review of more than 4000 papers that concluded there “is currently no consistent evidence that wind farms cause adverse effects in humans”.

“Overall, the body of evidence that directly examined wind farms and their potential health effects was small and of poor quality,” the NHMRC reported. “There is consistent by poor quality evidence that wind farm noise is associated with annoyance, as well as less consistent, poor quality direct evidence of an association between sleep disturbance and wind farm noise.”

The Council’s conclusions follow an exhaustive process involving the use of independent reviewers to scrutinise the NHMRC’s methodology in reviewing the scientific literature and evidence, as well as public consultations and a revised and updated literature review.

They echo the AMA’s own conclusion that there is no evidence to back assertions that wind farms cause headaches, dizziness, tachycardia or other health problems.

In a Position Statement released last year, the AMA said that if wind farms did directly cause adverse health effects, there would be a much stronger correlation between reports of symptoms and proximity to wind farms than currently existed.

The AMA Position Statement on Wind Farms and Health 2014, which can be viewed at position-statement/wind-farms-and-health-2014, concluded that “available Australian and international evidence does not support the view that the…sound generated by wind farms…causes adverse health effects”.

The NHMRC, however, has not closed the book on the issue, indicating that further research into the possible health effects of wind farms on people within 1500 metres “is warranted”.

The latest furore over the health effects of wind farms has come just weeks after the Government negotiated a cut in the Renewable Energy Target (RET) from 41,000 to 33,000 gigawatt hours.

Mr Abbott lamented that the Government had been unable to secure an even deeper reduction, which was arrived at following months of haggling between the major parties that destabilised the renewable energy industry and deterred investors.

“What we did recently in the Senate was reduce…capital R-E-D-U-C-E, the number of these things that we are going to get in the future,” the Prime Minister said, “I would frankly have liked to have reduced the number a lot more, but we got the best deal we could out of the Senate, and if we hadn’t had a deal…we would have been stuck with even more of these things.”

Adrian Rollins

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.

 

 

 

Briefs – 2 June 2015

Medical Research Future Fund on the way

More than a year after it was first announced, the Federal Government has finally introduced legislation to establish the Medical Research Future Fund.

The Fund, which the Government expects to grow to $20 billion by the end of the decade, has been under a cloud because several of the savings measures originally intended to finance it – particularly the GP co-payment – have been dumped or not yet passed.

But AMA President Associate Professor Brian Owler recently challenged the Government to stop dithering on the issue and set the Fund up, pointing out that a large swag of the measures designated to finance it were in place.

In introducing the enabling legislation, Treasurer Joe Hockey said the Fund would receive an initial endowment of $1 billion from the Health and Hospitals Fund and would build to reach $20 billion in 2019-20.

Mr Hockey said the first $10 million from the Fund would be distributed next financial year, and estimated that $400 million would be disbursed in the next four years.

The Fund will be managed by the Future Fund Board of Guardians, while a separate board will be established to provide expert advice on medical research priorities and strategy.

Adrian Rollins

Mersey Hospital two-year funding deal

Funding for Tasmania’s Mersey Community Hospital has been extended for two years following an in-principle agreement struck between the Commonwealth and Tasmanian governments.

Health Minister Sussan Ley said the Federal Government would pay its State counterpart $148.5 million to continue to manage and operate the hospital over the next two years.

The Mersey Hospital became the first and only public hospital to be directly funded by the Commonwealth when the Howard Government controversially assumed responsibility for the institution after the Tasmanian Government wanted to downgrade it to a day procedure centre, with only a limited overnight emergency capacity.

The intervention, which occurred just weeks before the 2007 Federal election that the Howard Government lost, was unprecedented at the time, and has not been repeated since.

Ms Ley said the deal provided certainty for the hospital while the Tasmanian Government undertakes reforms of the State health system.

Adrian Rollins

Govt promises cheaper, better medicines sooner

The Federal Government claims patients will get vital medicines more cheaply and much quicker following changes to the way pharmaceuticals are supplied under deals with industry it claims will save taxpayers $6.6 billion over the next five years.

Health Minister Sussan Ley said patients could save more than $100 a year under agreements the Commonwealth has struck with the pharmaceutical industry, while efforts to accelerate the listing of new medicines on the Pharmaceutical Benefits Scheme were beginning to pay off.

Ms Ley has signed a five-year deal with the Generic Medicines Industry Association to slash the cost of generic pharmaceuticals, including halving the price of common medicines for cholesterol, heart conditions and depression, potentially saving taxpayers about $3 billion over five years.

According to the Government, the changes mean that from October next year the cost of the widely-used cholesterol drug Atorvastatin could drop from $14.60 to $10.68, while the heart medicine Clopidogrel would fall from $14.01 to $10.38 and the depression treatment Venlafaxine would cost $11.65 instead of $16.52.

But consumer groups have warned that the decision to pay pharmacists a flat $3.49 fee (indexed to inflation) for dispensing medications instead of receiving a percentage of the price, will push the cost of many cheap medicines up.

The Consumer Health Forum said figures in the agreement showed consumers would “directly contribute” $8.2 billion to pharmacy owner remuneration in the next five years – around 34 per cent of the $23.6 billion to be paid to pharmacies for PBS medicines.

Forum Chief Executive Leanne Wells said that under the current agreement, consumers contributed 29 per cent of total payments.

The agreement includes bigger incentives for pharmacists to offer patients the option of using cheaper generic versions of medicines, backed by a $20 million media campaign.

The Government has already obtained the pharmacy industry’s grudging acceptance of an optional $1 discount on patient co-payments, and it has also negotiated agreement on lower prices for branded drugs for which there is no generic substitute.

In a measure expected to save about $1 billion, the Government will cut the price it is prepared to pay for branded medicines by 5 per cent after they have been listed on the Pharmaceutical Benefits Scheme for five years.

The Commonwealth is also implementing changes to how it calculates the price it pays for medicines when they go off-patent. Currently, the Government determines market price using a weighted average of the price of all brands.

But under the new arrangement, expected to come into effect from October next year, the original ‘premium’ brand will be excluded from the calculation, driving the average price down.

“Removing originator brands from price calculations for everyday medicines could see the price of common generic drugs halve for some patients, whilst also saving taxpayers $2 billion over five years,” Ms Ley said.

The Government also expects to save $610 million over five years by closing loopholes around the way combination drugs – where two separate medicines are combined to create a new patented medication – are subsidised.

As previously flagged, the Commonwealth also expects to save $500 million remove several low-cost over-the-counter medicines such as everyday painkillers from the PBS.

The Minister said Government efforts to speed up the listing of new medicines were also working, pointing out that there had been 652 new and amended listings on the PBS since it was elected in September 2013, compared with 331 listings during the previous three years.

Ms Ley said the chief independent scientific adviser on medicines, the Pharmaceutical Benefits Advisory Committee took an average of just 17 weeks to recommend whether or not a drug should be listed on the PBS – a turnaround that was one of the fastest in the world.

“We understand the importance of ensuring Australians have fast access to affordable medicines when and where they need them, and we are investing heavily to deliver this,” the Minister said.

PBAC’s operations have been reinforced by the appointment of leading cardiovascular disease specialist Professor Andrew Wilson as Chair, and Ms Ley said the Government would soon introduce legislation to expand PBAC’s membership from 18 to 21 in recognition of its increasing workload and the complexity of matters being considered by it.

“Expanding the capacity of the PBAC to deal with complex medicines is another important step to ensure Australians benefit from new medicines sooner,” she said.

And the Government expects Australia patients to get improved access to leading-edge medications with the launch of a website providing a one-stop shop regarding clinical trials happening around the world.

Evidence indicates that almost half of all phase three clinical trials conducted in Australia fell short of their patient recruitment targets, and Ms Ley said the website would make it easier for patients to find out about trials and take part in ground-breaking medical research.

Adrian Rollins

 

Talking About The Smokes: summary and key findings

Transforming the evidence to guide Aboriginal and Torres Strait Islander tobacco control

The baseline cross-sectional results from the Talking About The Smokes project outlined in this supplement (and summarised in the Box) provide the most detailed national evidence yet to guide practice and policy to reduce the harm caused by tobacco smoking among Aboriginal and Torres Strait Islander peoples. The national prevalence of daily smoking in the Aboriginal and Torres Strait Islander population is falling, but at 42% is still 2.6 times that of other Australians.1 Research evidence to guide Aboriginal and Torres Strait Islander tobacco control has been constrained by the uncertainties of generalising from small local research projects or from the large body of research in other populations. There have been competing hypotheses about whether Aboriginal and Torres Strait Islander smoking and quitting behaviour is similar to or different from other populations. These new results suggest many similarities with other populations.

We found the proportion of Aboriginal and Torres Strait Islander daily smokers who want to quit, have made a quit attempt in the past year, live in smoke-free homes and work in smoke-free workplaces is similar to that of the general population. Similar proportions also demonstrate knowledge of the most harmful health effects of smoking and hold negative personal attitudes towards smoking.

But there are also differences. Fewer Aboriginal and Torres Strait Islander daily smokers than other Australians have ever made a quit attempt or sustained a quit attempt for at least a month, and a lower proportion agree that social norms disapprove of smoking. Even though similar proportions agree that nicotine replacement therapy and stop-smoking medicines help smokers to quit, fewer have used these. In contrast, a higher proportion recalled being advised to quit by a health professional in the past year.

There are also differences in smoking and quitting behaviour and beliefs within the Aboriginal and Torres Strait Islander population, although the socioeconomic gradients were not consistent. For example, more employed people than those who were not employed wanted to quit, had ever tried to quit, had sustained a quit attempt for at least a month, knew about the harms of smoking, had a smoke-free home, had been advised to quit and had used nicotine replacement therapy or stop-smoking medicines. But there were no differences by employment status in quit attempts in the past year, recall of exposure to health information or in many of the attitudes towards smoking.

Using this new information, health staff working directly with Aboriginal and Torres Strait Islander smokers can be encouraged to do more, knowing that most of the smokers they see will want to quit, already know that smoking and passive smoking are harmful, and are likely to live in a smoke-free home and have a history of recent quit attempts. They can be confident that their messages will be understood and welcomed, then focus on the more difficult task of helping people to successfully sustain their quit attempts.

Those working in clinics can build on their existing good work in ensuring that most Aboriginal and Torres Strait Islander smokers regularly receive brief advice about smoking cessation. They can encourage more smokers to use evidence-based measures to prevent relapse during their next quit attempt, such as stop-smoking medicines, the telephone Quitline, and quit-smoking courses, clinics and groups.

Those working in health promotion will need to continue to reinforce and enhance social norms about being smoke-free, to encourage quit attempts and to support smokers trying to sustain quit attempts. There is a need for continued mainstream and national social marketing campaigns, especially those that build on the particular salience of Aboriginal and Torres Strait Islander smokers’ concerns about the harmful effects of their smoking on others. Local and Aboriginal and Torres Strait Islander campaigns also appear to be useful.

There are also messages for public health professionals, policymakers, funders and managers. They can justify investing health resources in tobacco control, not only because smoking causes 20% of Aboriginal and Torres Strait Islander deaths,2 but also because improvement is clearly possible. Our findings support maintaining an ongoing commitment to a comprehensive approach to Aboriginal and Torres Strait Islander tobacco control, rather than relying excessively on any single strategy or element. Those working directly with Aboriginal and Torres Strait Islander smokers should be made aware of this new evidence and aided in reorienting their practice to accommodate it. One of the specific challenges will be how to efficiently fund targeted social marketing activity, without wasting social marketing resources through too much fragmentation.3

Most recent national policy attention has concentrated on the large increase in dedicated funding initiated by the previous federal government through the Tackling Indigenous Smoking program, followed by the announced cuts to this funding and the review of the program in 2014. The information in this supplement is useful to guide the evolution of the program, but also reminds us that this is only part of the story. Aboriginal and Torres Strait Islander smoking is also being tackled through mainstream tobacco control activities (advertising campaigns, pack warnings and plain packaging, and smoke-free regulation) and activities already incorporated into routine health care (brief advice and individual cessation support).

This is only the beginning of the evidence that will emerge from the Talking About The Smokes project. It was designed primarily as a cohort study, and analyses of the prospective longitudinal data of the 849 recontacted smokers and ex-smokers will enable more definitive causal interpretations. The involvement of Aboriginal and Torres Strait Islander people and the Aboriginal community-controlled health service sector in all aspects of this project will facilitate the translation of the results into improved practices and policies that will reduce the harm caused by smoking in Aboriginal and Torres Strait Islander communities.

Key findings from the baseline survey of the Talking About The Smokes project

We interviewed a nationally representative sample of 2522 Aboriginal and Torres Strait Islander people from 35 locations across Australia, including 1643 smokers (1392 daily smokers), 78 ex-smokers who had quit ≤ 12 months before, 233 ex-smokers who had quit > 12 months before, and 568 never-smokers.

Quitting (doi: 10.5694/mja15.00202, 10.5694/mja15.00199, 10.5694/mja15.00105)

  • 70% of smokers want to quit
  • 69% of daily smokers had ever made a quit attempt
  • 48% of daily smokers had made a quit attempt in the past year
  • 47% of daily smokers who had made a quit attempt in the past 5 years had sustained an attempt for at least 1 month
  • 70% of daily smokers who had made a quit attempt in the past 5 years had strong cravings during their most recent quit attempt, and 72% found it hard to be around smokers

Second–hand smoke (doi: 10.5694/mja14.00876, 10.5694/mja15.00200)

  • 53% of daily smokers reported that smoking was never allowed anywhere inside their home
  • 88% of employed daily smokers reported that smoking was not allowed in any indoor area at their workplace
  • 77% of daily smokers agreed that smoking should be banned everywhere (both indoors and outdoors) at Aboriginal community-controlled health services, 93% agreed it should be banned indoors at other Aboriginal organisations, and 51% agreed it should be banned at outdoor festivals and sporting events

Knowledge of the health effects of smoking and second–hand smoke (doi: 10.5694/mja14.00877)

  • Most daily smokers reported knowing that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%)
  • Most daily smokers reported knowing that second-hand smoke is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%)

Personal attitudes towards smoking (doi: 10.5694/mja14.01535)

  • 78% of daily smokers agreed that if they had to do it over again, they would not have started smoking
  • 81% of daily smokers agreed that they spend too much money on cigarettes
  • 32% of daily smokers agreed that smoking is an important part of their life

Social norms about smoking (doi: 10.5694/mja14.01534)

  • 62% of daily smokers agreed that mainstream society disapproves of smoking, and 40% agreed that their local community leaders disapprove of smoking
  • 70% of daily smokers agreed that there are fewer and fewer places where they feel comfortable smoking
  • 90% of daily smokers agreed that being a non-smoker sets a good example to children

Anti-tobacco health information (doi: 10.5694/mja14.01628)

  • 65% of smokers recalled often noticing pack warning labels in the past month
  • 45% of smokers recalled often noticing anti-tobacco advertising or information in the past 6 months, most commonly on television
  • 48% of smokers recalled ever noticing any targeted advertising or information featuring Aboriginal and Torres Strait Islander people or artwork in the past 6 months, with 16% noticing advertising or information featuring local people or artwork

Cessation support (doi: 10.5694/mja15.00293, 10.5694/mja15.00205)

  • 75% of daily smokers who had seen a health professional in the past year had been advised to quit
  • 37% of daily smokers had ever used nicotine replacement therapy or stop-smoking medicines, and 23% had used them in the past year
  • Among all smokers and ex-smokers who had quit ≤ 12 months before, nicotine patches were most commonly used (24%), followed by varenicline (11%) and nicotine gum (10%)

We also surveyed 645 staff at 31 Aboriginal community-controlled health services, including 374 Aboriginal and Torres Strait Islander staff who had a lower age- and sex-standardised prevalence of smoking compared with a national sample of the Aboriginal and Torres Strait Islander population (doi: 10.5694/mja14.01523).