Indigenous health

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).

on behalf of the Talking About The Smokes project

Objective: To describe the research methods and baseline sample of the Talking About The Smokes (TATS) project. Design: The TATS project is a collaboration between research institutions and Aboriginal community-controlled health services (ACCHSs) and their state and national representative bodies. It is one of the studies within the International Tobacco Control Policy Evaluation Project, enabling national and international comparisons. It includes a prospective longitudinal study of Aboriginal and Torres Strait Islander smokers and recent ex-smokers; a survey of non-smokers; repeated cross-sectional surveys of ACCHS staff; and descriptions of the tobacco policies and practices at the ACCHSs. Community members completed face-to-face surveys; staff completed surveys on paper or online. We compared potential biases and the distribution of variables common to the main community baseline sample and unweighted and weighted results of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The baseline survey (Wave 1) was conducted between April 2012 and October 2013. Setting and participants: 2522 Aboriginal and Torres Strait Islander people in 35 locations (the communities served by 34 ACCHSs and one community in the Torres Strait), and 645 staff in the ACCHSs. Main outcome measures: Sociodemographic and general health indicators, smoking status, number of cigarettes smoked per day and quit attempts. Results: The main community baseline sample closely matched the distribution of the Aboriginal and Torres Strait Islander population in the weighted NATSISS by age, sex, jurisdiction and remoteness. There were inconsistent differences in some sociodemographic factors between our sample and the NATSISS: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas. In both surveys, similar percentages of smokers reported having attempted to quit in the past year, and daily smokers reported similar numbers of cigarettes smoked per day. Conclusion: The TATS project provides a detailed and nationally representative description of Aboriginal and Torres Strait Islander smoking behaviour, attitudes, knowledge and exposure to tobacco control activities and policies, and their association with quitting.

David P Thomas MB BS, PhD, FAFPHM · Viki L Briggs BA, GDipIndigHlthProm, MPH · Sophia Couzos FAFPHM, FACRRM, FRACGP · Maureen E Davey MB BS, FAFPHM · Jennifer M Hunt MPH, FAFPHM, PhD · Kathryn S Panaretto MB BS, MPH, FAFPHM · Anke E van der Sterren MPH, MA, BA · Matthew Stevens PhD, BSc(Hons) · Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD

Objective: To describe the Talking About The Smokes (TATS) project according to the World Health Organization guiding principles for conducting community-based participatory research (PR) involving indigenous peoples, to assist others planning large-scale PR projects. Design, setting and participants: The TATS project was initiated in Australia in 2010 as part of the International Tobacco Control Policy Evaluation Project, and surveyed a representative sample of 2522 Aboriginal and Torres Strait Islander adults to assess the impact of tobacco control policies. The PR process of the TATS project, which aimed to build partnerships to create equitable conditions for knowledge production, was mapped and summarised onto a framework adapted from the WHO principles. Main outcome measures: Processes describing consultation and approval, partnerships and research agreements, communication, funding, ethics and consent, data and benefits of the research. Results: The TATS project involved baseline and follow-up surveys conducted in 34 Aboriginal community-controlled health services and one Torres Strait community. Consistent with the WHO PR principles, the TATS project built on community priorities and strengths through strategic partnerships from project inception, and demonstrated the value of research agreements and trusting relationships to foster shared decision making, capacity building and a commitment to Indigenous data ownership. Conclusions: Community-based PR methodology, by definition, needs adaptation to local settings and priorities. The TATS project demonstrates that large-scale research can be participatory, with strong Indigenous community engagement and benefits.

Sophia Couzos FAFPHM, FACRRM, FRACGP · Anna K Nicholson GDipPH, BPhty(Hons) · Jennifer M Hunt MPH, FAFPHM, PhD · Maureen E Davey MB BS, FAFPHM · Josephine K May · Pele T Bennet BHSc · Darren W Westphal MPH · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe past attempts to quit smoking in a national sample of Aboriginal and Torres Strait Islander people, and to compare their quitting activity with that in the general Australian population. Design, setting and participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 smokers and 78 recent quitters between April 2012 and October 2013. Baseline results for daily smokers (n = 1392) are compared with results for daily smokers (n = 1655) from Waves 5 to 8.5 (2006–2012) of the Australian International Tobacco Control Policy Evaluation Project (ITC Project). Main outcome measures: Ever having tried to quit, tried to quit in the past year, sustained a quit attempt for 1 month or more. Results: Compared with the general population, a smaller proportion of Aboriginal and Torres Strait Islander daily smokers had ever tried to quit (TATS, 69% v ITC, 81.4%), but attempts to quit within the past year were similar (TATS, 48% v ITC, 45.7%). More Aboriginal and Torres Strait Islander daily smokers than those in the general population reported sustaining past quit attempts for short periods only. Aboriginal and Torres Strait Islander smokers whose local health services had tobacco control resources were more likely to have tried to quit, whereas men and people who perceived they had experienced racism in the past year were less likely. Younger smokers, those who had gone without essentials due to money spent on smoking, and those who were often unable to afford cigarettes were more likely to have tried to quit in the past year, but less likely to have ever sustained an attempt for 1 month or more. Smokers who were unemployed, those who had not completed Year 12 and those from remote areas were also less likely to sustain a quit attempt. Conclusions: Existing comprehensive tobacco control programs appear to be motivating Aboriginal and Torres Strait Islander smokers to quit but do not appear to overcome challenges in sustaining quit attempts, especially for more disadvantaged smokers and those from remote areas.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Maureen E Davey MB BS, FAFPHM · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objective: To describe factors that predict wanting to quit smoking in a national sample of Aboriginal and Torres Strait Islander people. Design, setting and participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 1643 current smokers between April 2012 and October 2013. Main outcome measure: Wanting to quit smoking. Results: More than two-thirds of smokers (70%) said they want to quit. Many factors were associated with wanting to quit, including past quitting activity. Interest in quitting was lower among men and smokers from economically disadvantaged areas, but there was no difference by age, remoteness or other measures of economic disadvantage. Attitudes and beliefs negatively associated with wanting to quit included enjoying smoking and believing quitting to be very difficult, and those positively associated included regretting ever starting to smoke, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, worrying about future smoking-related health effects and believing quitting to be beneficial. Reporting support from family and friends was predictive of wanting to quit, but factors related to smoking in the social network were not. Associations with health and wellbeing were mixed. While most tobacco control policy exposure variables were positively associated with wanting to quit, two — receiving advice to quit from a health professional, and recall of targeted anti-tobacco advertising — appeared to have an effect that extended beyond influencing relevant attitudes and beliefs. Conclusion: Interest in quitting among Aboriginal and Torres Strait Islander smokers appears to be influenced by a broad range of factors, highlighting the importance of taking a comprehensive approach to tobacco control. Advice from health professionals and targeted advertising appear to be important intervention strategies.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Maureen E Davey MB BS, FAFPHM · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objective: To examine Aboriginal and Torres Strait Islander people's protection from second-hand smoke at home and work. Design, setting and participants: The Talking About The Smokes project surveyed 2522 Aboriginal and Torres Strait Islander people from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait, using quota sampling, from April 2012 to October 2013. We made comparisons with data from Australian smokers in the International Tobacco Control Policy Evaluation Project (ITC Project), collected from either July 2010 to May 2011 or September 2011 to February 2012. Main outcome measures: Whether smoking was not allowed anywhere in the home, or not allowed in any indoor area at work. Results: More than half (56%) of Aboriginal and Torres Strait Islander smokers and 80% of non-smokers reported that smoking was never allowed anywhere in their home. Similar percentages of daily smokers in our sample and the Australian ITC Project data reported bans. Most employed Aboriginal and Torres Strait Islander daily smokers (88%) reported that smoking was not allowed in any indoor area at work, similar to the Australian ITC Project estimate. Smokers working in smoke-free workplaces were more likely to have smoke-free homes than those in workplaces where smoking was allowed indoors (odds ratio, 2.85; 95% CI, 1.67–4.87). Smokers who lived in smoke-free homes were more likely to have made a quit attempt in the past year, to want to quit, and to have made quit attempts of 1 month or longer. Conclusion: Most Aboriginal and Torres Strait Islander people are protected from second-hand smoke at work, and similar proportions of Aboriginal and Torres Strait Islander smokers and other Australian smokers do not allow smoking inside their homes.

David P Thomas MB BS, PhD, FAFPHM · Kathryn S Panaretto MB BS, MPH, FAFPHM · Matthew Stevens PhD, BSc(Hons) · Pele T Bennet BHSc · Ron Borland PhD

Objectives: To examine indicators of nicotine dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers and their association with sustaining a quit attempt for at least 1 month, and to make comparisons with a national sample of Australian daily smokers. Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit 1392 daily smokers from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait from April 2012 to October 2013. These were compared with 1010 daily smokers from the general Australian population surveyed by the International Tobacco Control Policy Evaluation Project from September 2011 to February 2012. Main outcome measures: Cigarettes per day (CPD), time to first cigarette, Heaviness of Smoking Index (HSI), other indicators of dependence, and whether smokers had ever sustained a quit attempt for at least 1 month. Results: There was little difference in the mean HSI scores for Aboriginal and Torres Strait Islander and other Australian daily smokers. A higher proportion of Aboriginal and Torres Strait Islander daily smokers smoked ≤ 10 CPD (40% v 33.4%), but more also smoked their first cigarette within 30 minutes of waking (75% v 64.6%). 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%). Most Aboriginal and Torres Strait Islander smokers reported experiencing difficulties during their most recent quit attempt. All indicators of dependence, except CPD and strong urges, were positively associated with not having made a sustained quit attempt. Reported difficulties during the most recent quit attempt were more strongly associated with being unable to sustain quit attempts than were traditional measures of dependence. Conclusion: Aboriginal and Torres Strait Islander smokers' experiences of past attempts to quit may be more useful than conventional indicators of nicotine dependence in understanding their dependence.

David P Thomas MB BS, PhD, FAFPHM · Kathryn S Panaretto MB BS, MPH, FAFPHM · Matthew Stevens PhD, BSc(Hons) · Ron Borland PhD

Objectives: To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting. Design, setting and participants: The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013. Main outcome measures: Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit. Results: Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not. Conclusion: Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Sophia Couzos FAFPHM, FACRRM, FRACGP · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters and assess how they are associated with quitting, and to compare these attitudes with those of smokers in the general Australian population. Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers and 78 recent quitters from April 2012 to October 2013. Main outcome measures: Personal attitudes towards smoking and quitting, wanting to quit, and attempting to quit in the past year. Results: Aboriginal and Torres Strait Islander daily smokers were less likely than daily smokers in the general Australian population to report enjoying smoking (65% v 81%) and more likely to disagree that smoking is an important part of their life (49% v 38%); other attitudes were similar between the two groups. In the Aboriginal and Torres Strait Islander sample, non-daily smokers generally held less positive attitudes towards smoking compared with daily smokers, and ex-smokers who had quit within the past year reported positive views about quitting. Among the daily smokers, 78% reported regretting starting to smoke and 81% reported spending too much money on cigarettes, both of which were positively associated with wanting and attempting to quit; 32% perceived smoking to be an important part of their life, which was negatively associated with both quit outcomes; and 83% agreed that smoking calms them down when stressed, which was not associated with the quitting outcomes. Conclusions: Aboriginal and Torres Strait Islander smokers were less likely than those in the general population to report positive reasons to smoke and held similar views about the negative aspects, suggesting that factors other than personal attitudes may be responsible for the high continuing smoking rate in this population.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Pele T Bennet BHSc · Anke E van der Sterren MPH, MA, BA · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander people, and to assess the relationship of these beliefs with quitting. Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers, 311 ex-smokers and 568 never-smokers from April 2012 to October 2013. Main outcome measures: Eight normative beliefs about smoking; wanting and attempting to quit. Results: Compared with daily smokers in the general Australian population, Aboriginal and Torres Strait Islander daily smokers were less likely to report that mainstream society disapproves of smoking (78.5% v 62%). Among Aboriginal and Torres Strait Islander daily smokers, 40% agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking, 70% said there are increasingly fewer places they feel comfortable smoking, and most (90%) believed non-smokers set a good example to children. Support for the government to do more to tackle the harm caused by smoking was much higher than in the general Australian population (80% v 47.2%). These five normative beliefs were all associated with wanting to quit. Non-smokers reported low levels of pressure to take up smoking. Conclusion: Tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Anke E van der Sterren MPH, MA, BA · Pele T Bennet BHSc · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM