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

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

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

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

Methods

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

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

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

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

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

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

Statistical analyses

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

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

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

Results

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

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

Strengths and limitations

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

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

Ever used NRT or SSMs

Used NRT or SSMs in the past year

Smoking characteristic

% (frequency)*

Odds ratio (95% CI)†

P‡

% (frequency)*

Odds ratio (95% CI)†

P‡

Smokers and recent ex-smokers (n = 1721)

Smoking status

Daily smokers

37% (515)

1.0

< 0.001

23% (318)

1.0

0.001

Non-daily smokers

17% (43)

0.35 (0.24–0.51)

12% (30)

0.46 (0.29–0.73)

Recent ex-smokers§

36% (28)

0.94 (0.57–1.55)

32% (25)

1.59 (0.95–2.66)

Daily smokers only (n = 1369)

Heaviness of Smoking Index score

Low (0–1)

30% (69)

1.0

< 0.001

18% (42)

1.0

0.06

Moderate (2–3)

36% (284)

1.34 (1.00–1.81)

23% (184)

1.39 (0.92–2.08)

Heavy (4–6)

45% (148)

1.98 (1.42–2.76)

27% (86)

1.65 (1.08–2.51)

RACGP criteria for dependence¶

None

24% (38)

1.0

< 0.001

13% (20)

1.0

< 0.001

One

27% (91)

1.23 (0.78–1.92)

17% (55)

1.38 (0.84–2.28)

Two

35% (192)

1.71 (1.12–2.61)

21% (118)

1.89 (1.11–3.22)

All three

59% (193)

4.66 (2.99–7.27)

39% (125)

4.39 (2.56–7.51)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methods

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

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

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

Statistical analyses

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

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

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

Results

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

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

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

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

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

Discussion

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

Strengths and limitations

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

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

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

Comparisons with other studies

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

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

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

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

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

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

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

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

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

Australian ITC Project, % (95% CI)†

TATS project, % (frequency)‡

Seen a health professional

68.1% (64.8%–71.1%)

76% (1047)

Of those seen

Asked if he/she smokes§

—

93% (968)

Advised to quit

56.2% (52.3%–59.9%)

75% (782)

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

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

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

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

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

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

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

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

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

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

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

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

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

Tobacco control policies and activities in Aboriginal community-controlled health services

Aboriginal community-controlled health services (ACCHSs) have long recognised tobacco use as an important contributor to poor health outcomes in their communities,1 and have worked to reduce this burden with a range of tobacco control initiatives. The ACCHS sector includes about 150 health services across Australia, each governed and managed by its local Aboriginal community, as well as representative state or territory organisations (Affiliates) and the National Aboriginal Community Controlled Health Organisation (NACCHO).

In 2001, NACCHO surveyed 67 staff from Aboriginal health services, 124 Aboriginal and Torres Strait Islander community members from 13 locations, and 76 health services with predominantly Aboriginal and Torres Strait Islander clients.2 The survey identified high levels of knowledge about the harmful health effects of tobacco, a lack of specific tobacco control programs and the need for more information on effective stop-smoking interventions. The report recommended that governments prioritise and fund tobacco control through policies that deal with social determinants of smoking, workforce training, comprehensive long-term programs to reduce smoking, and ongoing evaluation. For ACCHSs, the report recommended making tobacco control a specific priority and integrating it into health service programs.

Since 2001, specific tobacco control programs have been widely implemented in ACCHSs, informed by evidence from individual evaluations and randomised controlled trials of Aboriginal tobacco control interventions,3–5 and literature reviews.6–9 ACCHSs have also learnt from each other by sharing examples of what has (or has not) worked well.10–12

In 2008, the federal government increased support through the $14.5 million Indigenous Tobacco Control Initiative over 3 years, followed in 2009 by a $100.6 million commitment over 4 years to the Council of Australian Governments’ Tackling Indigenous Smoking measure.13,14 These funded social marketing, quit support and other programs, with the goal of halving smoking rates in Aboriginal and Torres Strait Islander communities by 2018. Forty ACCHSs and three NACCHO Affiliates received funds for tobacco control activities under these initiatives. Smoke-free workplace policies for ACCHSs and other organisations delivering Aboriginal primary health care were mandated in funding contracts with the Australian Government from July 2012.15

These tobacco control activities occurred in the wider Australian context of expanding smoke-free legislation, increases in tobacco taxation, plain packaging of cigarettes and ongoing social marketing campaigns.

The Talking About the Smokes (TATS) project, part of the International Tobacco Control Policy Evaluation Project, aims to assess the impact of tobacco control policies on the Aboriginal and Torres Strait Islander population. Here, we describe the tobacco control policies, activities and programs reported by the ACCHSs participating in the TATS project.

Methods

The TATS project involved 35 communities served by 34 ACCHSs and one community in the Torres Strait where there is no ACCHS and health services are provided by Queensland Health. ACCHSs were selected to reflect the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. The methods are described in detail elsewhere.16,17

Briefly, at 30 sites, we aimed to survey up to 50 smokers or ex-smokers who had quit ≤ 12 months before and 25 non-smokers, with equal numbers of men and women and those aged 18–34 years and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. Between April 2012 and October 2013, trained local interviewers completed the 30–60 minute community surveys face to face using a computer tablet. The community sample closely matched the distribution of age, sex, jurisdiction, remoteness and number of cigarettes smoked per day reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey. However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.17

The TATS project also invited representatives at each site to complete a single policy monitoring survey, including questions about health service size and location; tobacco control funding, resources and policies; cessation support; and advocacy. The policy monitoring surveys were paper-based, designed to take less than 10 minutes, and were completed by staff members selected by the ACCHS. Policy monitoring surveys were completed while community surveys were being conducted at that site. Questions from the policy monitoring and community surveys analysed here are listed in Appendix 1.

Statistical analyses

We report the numbers of ACCHSs with different levels of tobacco control resourcing, activities and smoke-free policies; and the percentage and frequency of community members supporting smoking bans. Using the χ2 test, we assessed variation between services by size of service (< 50 or ≥ 50 staff); whether the service had received dedicated tobacco control funding in the past year; and its reported prioritisation of tobacco control in the past year (“not at all”, “just a little”, “a fair amount” or “a great deal”).

At the first project site, the question about prioritisation of tobacco control was not asked, and two questions about dispensing and prescribing free nicotine replacement therapy were asked as a single question. Less than 0.5% of respondents to the community survey did not answer the questions about smoking bans. These missing values were excluded from our analyses. We also excluded results from the Torres Strait community without an ACCHS.

Results

The 32 completed policy monitoring surveys describe tobacco control activities at 34 sites, as a single survey was completed by the umbrella ACCHS for three participating sites in one area. Nineteen services had 50 or more staff and 13 had fewer than 50.

Tobacco control resourcing and activities at ACCHSs

Nineteen of 32 ACCHSs reported receiving specific funding for tobacco control programs in the past 12 months. Another three used untied funds for tobacco control programs. Dedicated tobacco control funding was not associated with the size of the ACCHS (P = 0.84) or its reported prioritisation of tobacco control (P = 0.19). Thirteen ACCHSs reported prioritising tobacco control a great deal, 11 a fair amount and seven just a little. Eighteen ACCHSs had a staff position with a major focus on tobacco control.

Staff of 27 services had attended tobacco control training in the past year. There was no association between staff attending training and the size of the service (P = 0.31) or dedicated tobacco control funding (P = 0.34). However, there was an association with the prioritisation of tobacco control (P = 0.04), with some staff attending training at all 13 ACCHSs that had prioritised it a great deal. The training had been provided by a range of organisations, including NACCHO Affiliates, the Centre for Excellence in Indigenous Tobacco Control, cancer councils, quit organisations and state health departments.

In the past 12 months, 17 of 32 services had run programs to help people quit smoking. These included Aboriginal-specific tobacco control and healthy lifestyle programs, as well as mainstream quit programs. In all but one of these services, Aboriginal health workers or tobacco action workers were involved in running the program. Programs had been evaluated in nine services, some with internal surveys and others with the assistance of NACCHO Affiliates or universities.

Free nicotine replacement therapy was prescribed or dispensed by 25 of the 32 services. Most ACCHSs (21/34) supported staff who smoked by providing them with extra smoking cessation support, either by facilitating access to programs available to clients or through specific programs for staff.

Smoke-free workplace policies

All ACCHSs reported having a formal smoke-free policy in place. The features of these policies and the reported levels of adherence are described in Box 1. In contrast, only 18 of 32 services reported that most or all other Aboriginal and Torres Strait Islander organisations in their community were smoke-free; 10 reported that some were smoke-free and four that none were.

Community survey respondents (n = 2435) reported a high level of support for smoking bans everywhere at ACCHSs and indoors at other Aboriginal organisations, with less (but still majority) support for bans at outdoor community events (Box 2). Among the daily smokers who did not support total bans at ACCHSs, 82% (251/306) supported indoor bans. Daily smokers were least likely to support any of the bans.

Health promotion

All 32 ACCHSs provided locally or externally produced quit-smoking information to their communities, most commonly using posters, pamphlets and displays at information days or other community events, but also using newer media such as the internet and social media (Box 3). Health services with dedicated tobacco control funding were more likely to use locally developed posters (P = 0.03) and pamphlets (P = 0.02) in the clinic, and to give pamphlets to other organisations (P = 0.02), but there were no significant associations with funding when these locally developed items were considered together with externally developed information, or for other types of information. Ten services reported smoking or quitting stories featuring someone from their health service in mainstream or Aboriginal and Torres Strait Islander television, radio or newspaper news.

Nineteen ACCHSs reported discussing tobacco control policy at meetings with government and non-government organisations in the previous year, with 11 reporting that they had influenced local, regional or national tobacco control policy.

Discussion

We found that tobacco control initiatives are a priority in ACCHSs, with all reporting smoke-free workplace policies to reduce smoking and exposure to second-hand smoke. Staff with specific tobacco control training are providing a range of evidence-informed quit-smoking programs in health services and in the wider Aboriginal and Torres Strait Islander community. This increased tobacco control activity was not just found in health services with dedicated Aboriginal and Torres Strait Islander tobacco control funding.

Elsewhere in this supplement, we show that more community members from sites with dedicated tobacco control resources had been advised to quit,18 recalled noticing cigarette pack warning labels,19 made quit attempts20 and used stop-smoking medicines21 than those from sites without dedicated resources. However, there were no such significant differences for wanting to quit,22 smoke-free homes,23 recalling advertising and news stories about smoking and quitting,19 and personal attitudes towards smoking.24

A limitation to our study is that although the selected ACCHSs are geographically representative of the Aboriginal and Torres Strait Islander population, the ACCHSs that responded to the call for participation are likely to be biased towards those that were more interested and active in tobacco control. Further, the people completing the policy survey may have been unaware of all services and policies or may have overstated what was being provided. It was difficult to categorise services by their level of tobacco control activity because of the differences in the range of activities offered. Consequently, it was not possible to detect a relationship between dedicated funding and level of tobacco control activity. Furthermore, the small number of health services in our study did not allow identification of enablers and barriers to services prioritising tobacco control work, a useful area to explore in future research.

Our findings on smoke-free policies are not surprising, given implementing smoke-free work environments became a condition of funding for ACCHSs at the same time this study was conducted.15 However, it is likely that some aspects of these policies pre-dated the funding requirement, given that all 76 Aboriginal health services surveyed in 2001 reported indoor smoking bans, with the policies of 32% of services including broader measures.2 Our results provide evidence that many ACCHSs have more comprehensive policies, such as banning staff from smoking with clients and other staff or where they can be seen or while in uniform, and the provision of cessation support for staff. The incremental approach of ACCHSs in developing and strengthening policy content and implementation has common ground with government approaches to tobacco control, where success with indoor smoking bans was followed by an emphasis on initial exceptions, such as pubs and prisons, and on outdoor areas such as outdoor dining areas and street malls.25

The high level of community support for smoking bans that we found may reflect the wider tobacco control environment and the active involvement of ACCHS managers, staff and the community in tobacco control over the preceding decade. ACCHSs reported that policies relating to smoking behaviour of Aboriginal staff and the community have evolved over time, as the measures have been contested and negotiated in various Aboriginal community forums. This has included discussions about the right to smoke and the right to be protected from second-hand smoke, the social inclusion of sharing cigarettes and the significance of denormalising smoking and modelling healthier behaviour to children.11,26

The relatively small size of many ACCHSs provides an environment to test out policy measures that can then be either discarded as unacceptable or ineffective, or promoted as successful measures to other Aboriginal, community and health organisations. A key characteristic of ACCHSs is that a community with a high prevalence of smoking is involved in making and implementing decisions in areas they can control, such as workplaces and community events, thus providing Aboriginal leadership and contributing to shifts in social norms in their community. Aboriginal health services are well placed to influence social norms because of the large number of Aboriginal and Torres Strait Islander people who work there and use their services — 3618 full-time equivalent staff and 314 000 clients in 2012–13.27 There is an opportunity for ACCHSs to influence other Aboriginal and Torres Strait Islander organisations in their communities that do not have smoke-free policies.

It would be useful to monitor the diffusion of the successful and innovative tobacco control work both within and beyond the ACCHS sector, and to look to ACCHSs for new ideas in the future. The high level of commitment and experience in ACCHSs provides a strong base for sustainable interest and activity to further reduce smoking levels and smoking-related harm.

1 Smoke-free policies at health services (n = 32)

Policy details	Health services

Policy content
No smoking indoors	32
Designated outdoor smoking area	12
No smoking indoors or outdoors within the boundary/fence of health service	28
No smoking in work vehicles	32
No smoking in health service uniform	18
No smoking in work time	9
Other*	5
How the policy was communicated
Written policy	32
Signs	28
Staff meetings and/or newsletters	25
How many staff and clients follow all elements of the policy
Almost all	17
Most	11
Some	3
Only a few	1

* Such as no staff smoking with clients or other staff, when offsite in an official capacity or outside designated meal breaks.

2 Aboriginal and Torres Strait Islander community support for smoke-free environments (n = 2435)*

Smoking ban	Daily smokers (n = 1342)	Non-daily smokers (n = 233)	Ex-smokers (n = 299)	Never-smokers (n = 561)

Smoking should be banned everywhere at ACCHSs	77% (1030)	85% (197)	85% (255)	87% (487)
Smoking should be banned indoors at other Aboriginal organisations	93% (1242)	93% (217)	95% (284)	97% (544)
Smoking should be banned at outdoor festivals and sporting events	51% (687)	70% (163)	65% (194)	71% (398)

ACCHSs = Aboriginal community controlled health services. * Results are based on the respondents who “agree” or “strongly agree” with each statement and exclude those who did not answer.

3 Health services using different media to disseminate quit-smoking information (n = 32)

Quit-smoking information	Health services

Posters in clinic	31
Pamphlets in clinic	29
Health information days and events	28
Displays at other community events	26
Posters in other community locations	23
Pamphlets given to other organisations	21
Newsletters	18
Website	14
Social media	12
Newspaper or community magazine	11
Local radio advertisement	11
CD/DVD	11
Local television advertisement	2
Mobile phone messages	2

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

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

Statistical analyses

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

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

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

Results

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

Strengths and limitations

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

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

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

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

Indicator of dependence

Talking About The Smokes project, % (frequency)†

Australian ITC Project,
% (95% CI)‡

Cigarettes per day

1–10

40% (547)

33.4% (27.9%–39.3%)

11–20

39% (528)

42.2% (36.8%–47.7%)

21–30

18% (242)

18.5% (14.7%–22.9%)

≥ 31

4% (54)

6.0% (3.7%–9.6%)

Time to first cigarette

More than 60 minutes

9% (125)

16.1% (11.9%–21.3%)

31–60 minutes

16% (220)

19.4% (15.3%–24.2%)

6–30 minutes

64% (884)

46.7% (41.2%–52.3%)

5 minutes or less

11% (145)

17.9% (13.6%–23.2%)

Heaviness of Smoking Index (HSI) score

Low (0–1)

17% (234)

24.5% (19.5%–30.3%)

Moderate (2–3)

59% (796)

44.6% (39.2%–50.1%)

Heavy (4–6)

24% (328)

30.9% (25.8%–36.5%)

How often do you get strong urges to smoke?

Never or less than daily

21% (291)

12.4% (9.0%–16.9%)

Daily

27% (375)

26.9% (21.9%–32.5%)

Several times a day or more often

51% (706)

60.7% (54.9%–66.2%)

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

Very or somewhat easy

17% (234)

10.4% (6.9%–15.4%)

Neither easy nor hard

11% (156)

7.9% (5.0%–12.2%)

A little bit hard

32% (439)

33.7% (28.8%–39.0%)

Very hard

39% (537)

47.9% (42.3%–53.6%)

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

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

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

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

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

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

Indicator of dependence	Daily smokers, % (frequency)*

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

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

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

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

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

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

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

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

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

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

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

Methods

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

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

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

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

Statistical analyses

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

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

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

Results

Smoke-free homes

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

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

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

Smoke-free workplaces

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

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

Association with quit attempts and wanting to quit

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

Discussion

Smoke-free homes

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

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

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

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

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

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

Smoke-free workplaces

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

Association with quit attempts and wanting to quit

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

Strengths and limitations

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

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

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

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

1 Smoking bans in homes and workplaces*

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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).

[Editorial] Rewarding true inquiry and diligence in research

On May 31, about 600 delegates from over 50 countries and all continents will gather in Rio de Janeiro, Brazil, for the 4th World Conference on Research Integrity. The inaugural 1st World Conference was held in Lisbon, Portugal, 8 years ago. Attendees heard debates about whether scientific misconduct needed to be addressed or whether science could keep its own house in order. Examples of egregious misconduct featured strongly. And although the main goal of the first conference was to raise awareness of the importance of research integrity globally, the emphasis was on misconduct, its definitions and causes.

[Editorial] Strengthening clinical research in children and young people

“The time has come to protect children and young people through research not from research”, said Bobbie Farsides, Professor of Bioethics at Brighton and Sussex Medical School and Chair of the Working Party for the Nuffield Council on Bioethics, which published its report Children and clinical research: ethical issues on May 14. “It will always be easier to say ‘no’ to research with children on the grounds that it’s too difficult, but we should challenge the idea that it is acceptable to continue to offer health care to children without seeking to improve the evidence base for many of the treatments provided”, added Farsides.

The future of electronic cigarette growth depends on youth uptake

Simon Chapman discusses the phenomenon of “e-cigarettes” and the potential risks associated with their use

The New South Wales Government recently announced that it will outlaw the sale of electronic cigarettes (ECs) to minors. For the unfamiliar, ECs are battery-powered vaporisers that produce an aerosol or vapour containing nicotine and other substances, rather than cigarette smoke, which the user inhales. Parallel laws banning sales of tobacco products to children have existed in Australian states since 1900.1 These laws have long been ignored by many retailers2 and are poorly enforced. Prosecutions are rare, with the laws being largely symbolic gestures.

The tobacco industry long ago perfected pious expressions of public concern about juvenile smoking, while knowing how essential new cohorts of young smokers are to its very survival as an industry. Private acknowledgement of its own duplicity was hardly surprising:3

… this is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.

Equally, any manufacturer or retailer of ECs wanting to maximise sales appreciates the critical importance of building demand for these products in the young, as well as the social and political unacceptability of being candid about this. Today, an ever-diminishing 12.8% of Australians aged 14 years and over smoke on a daily basis.4 The record low uptake of smoking by the young is most responsible for this. The prospect of the industry reversing this inexorably ruinous exodus has been given a major boost with the arrival of ECs.

Tobacco companies’ investment in e-cigarettes

All tobacco transnationals have invested in ECs, with none desisting from their efforts to attack and dilute potent tobacco control policies nor announcing any phase-out of their combustible products. From this, we can conclude that the companies’ best hopes are for people to smoke and to use ECs or “vape”, not to use ECs instead of smoking. At a population level, this would be harm increasing, not reducing.5 Successful EC start-up companies are being bought up by tobacco companies, so the future of ECs is likely to be in lockstep with those companies’ ambitions, driven by their concern to preserve and grow immensely more profitable cigarette sales and to maximise the hours in a day when their products can be consumed.

Australian data on daily EC use are unavailable, with a 2013 national survey finding that 15.4% of smokers aged 14 years or over had used them at least once in the past 12 months,6 despite sales of nicotine liquid or “juice” being illegal here. In the United States, where ECs are freely available and heavily marketed, rising EC use by youths has now surpassed their falling cigarette smoking prevalence.7 EC advocates argue that there is thus no evidence for any gateway effect where nicotine initiation through vaping predicts uptake of smoking at higher rates than would occur without EC use. But smoking by young people has been in continual decline since 1994 in England8 and 1997 in the US9 and Australia,10 all well before the advent of ECs. Net transitioning to cigarettes or dual use with ECs in minors might be camouflaged by these broader declines. Future research will inform this important question.

Here though, a potential coalmine canary comes from a repeated Polish cross-sectional study, blithely dismissed as an outlier by vaping advocates. It found current use of ECs among Polish adolescents was dramatically higher in a 2013–14 sample than in a 2010–11 sample (29.9% v 5.5%) and that the prevalence of smoking tobacco cigarettes also increased (38% v 23.9%).11

The internet is awash with aggressive advertising for ECs,12 and the wide range of models available13 make them highly attractive to young people acutely hungry for ever-changing technology with edgy semiotics. A website sponsored by cigarette manufacturer Lorillard, which also sells Blu ECs, once stated knowingly:14

Kids may be particularly vulnerable to trying e-cigarettes due to an abundance of fun flavors such as cherry, vanilla, pina-colada and berry.

Many chemical flavourants in ECs have been approved for ingestion in foods, but not for inhalation15 up to 200 times a day, as occurs with ECs.16

The evidence relating to e-cigarette use

The volume and quality of the evidence for ECs being superior to unassisted quitting is small and often compromised by serious selection bias. EC users or “vapers” who have quit smoking understandably like to share their stories. But we have little population data on the extent to which ECs are causing prevarication about quitting, through erroneous beliefs that simply reducing smoking while dual using is harm reducing.17–19 One review concluded that real-world EC use is associated with significantly lower odds of quitting cigarettes.20

A recent systematic review of the evidence on the health risk profile of ECs concluded:21

Due to the many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up, no firm conclusions can be drawn on the safety of ECs …

Should the many hopes be realised that ECs do indeed pose minimal health risks and significantly assist in smoking cessation, future policy development in Australia will need to carefully consider how adult smokers wanting access to these products can best be facilitated without reversing the decades-long decline in youth smoking.

EC proponents argue that nicotine is almost benign in the doses obtained through vaping. However, there is growing evidence about the role of nicotine in carcinogenesis22 and the International Agency for Research on Cancer has recently prioritised the assessment of nicotine’s carcinogenicity.23

Pied Pipers in the vaping and tobacco industries have attempted to argue that concern about EC uptake in youth who would have never used any nicotine product is nothing but barely disguised moralism, akin to railing against innocuous caffeine. If they are right, those urging caution about soft touch regulation will have simply been wrong. But if the EC advocates are wrong, a less than benign genie with its pharmacological clutches around millions of young people may be extremely difficult to put back in the bottle.