Indigenous health

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

Objectives: To describe tobacco control policies and activities at a nationally representative sample of Aboriginal community-controlled health services (ACCHSs). Design, setting and participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit 34 ACCHSs around Australia. Between April 2012 and October 2013, a representative at each ACCHS completed a survey about the service's tobacco control policies and activities. Questions about support for smoke-free policies were also included in the TATS project survey of 2435 Aboriginal and Torres Strait Islander members of the communities served by the ACCHSs. Main outcome measures: ACCHS tobacco control policies and activities. Results: Thirty-two surveys were completed, covering 34 sites. Most ACCHSs (24/32) prioritised tobacco control “a great deal” or “a fair amount”, and all services had smoke-free workplace policies. Most had staff working on tobacco control and had provided tobacco control training within the past year. A range of quit-smoking information and activities had been provided for clients and the community, as well as extra smoking cessation support for staff. There was strong support for smoke-free ACCHSs from within the Aboriginal communities, with 87% of non-smokers, 85% of ex-smokers and 77% of daily smokers supporting a complete ban on smoking inside and around ACCHS buildings. Conclusions: The high level of commitment and experience within ACCHSs provides a strong base to sustain further tobacco control measures to reduce the very high smoking prevalence in Aboriginal and Torres Strait Islander populations.

Maureen E Davey MB BS, FAFPHM · Jennifer M Hunt MPH, FAFPHM, PhD · Raylene Foster GradCertBus, DipCommunityServ(AlcoholDrugsMental Health) · Sophia Couzos FAFPHM, FACRRM, FRACGP · Anke E van der Sterren MPH, MA, BA · Jasmine Sarin BHSci(IndigHlth) · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit. Design, setting and participants: A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013. Main outcome measures: Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit. Results: More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising. Conclusions: Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Jasmine Sarin BHSci(IndigHlth) · Sharon Wallace AdvDipHSci · Anke E van der Sterren MPH, MA, BA · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objectives: To 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 their association with quit attempts. Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit 1721 smokers and ex-smokers who had quit ≤ 12 months previously from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline surveys were conducted from April 2012 to October 2013. Results for daily smokers were compared with 1412 Australian daily smokers surveyed by the International Tobacco Control Policy Evaluation Project between 2006 and 2011. Main outcome measures: Participants' recall of having been: seen by a health professional in the past year, asked if they smoke, advised to quit, and referred to other cessation support services; and having made a quit attempt in the past year. Results: Compared with other Australian daily smokers, higher proportions of Aboriginal and Torres Strait Islander daily smokers saw a health professional in the past year (76% v 68.1%) and were advised to quit smoking (75% v 56.2% of those seen). Most Aboriginal and Torres Strait daily smokers who saw a health professional recalled being asked if they smoke (93%). Aboriginal and Torres Strait Islander daily smokers who had been advised to quit were more likely to have made a quit attempt in the past year than those who had not (odds ratio, 2.00; 95% CI, 1.58–2.52). Among all Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had been advised to quit, 49% were given a pamphlet or brochure on how to quit, but fewer were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%). Conclusion: Most Aboriginal and Torres Strait Islander daily smokers recalled being recently advised by a health professional to quit, which was associated with making a quit attempt.

David P Thomas MB BS, PhD, FAFPHM · Pele T Bennet BHSc · Viki L Briggs BA, GDipIndigHlthProm, MPH · Sophia Couzos FAFPHM, FACRRM, FRACGP · Jennifer M Hunt MPH, FAFPHM, PhD · Kathryn S Panaretto MB BS, MPH, FAFPHM · Matthew Stevens PhD, BSc(Hons) · Ron Borland PhD

Objective: To examine smoking among Aboriginal and Torres Strait Islander staff of Aboriginal community-controlled health services (ACCHSs). Design, setting and participants: The Talking About The Smokes (TATS) project surveyed 374 Aboriginal and Torres Strait Islander staff at a national sample of 31 ACCHSs, from April 2012 to October 2013. We made comparisons with adult participants in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) and with 1643 smokers in a community sample of 2522 Aboriginal and Torres Strait Islander people also surveyed in the TATS project. Main outcome measures: Smoking status, smoking behaviour at work, quitting behaviour, attitudes and beliefs about smoking and quitting. Results: Aboriginal and Torres Strait Islander ACCHS staff had a lower smoking prevalence than among all Aboriginal and Torres Strait Islander adults surveyed in the NATSISS (38% v 49.8%), but this difference was smaller when compared with only employed adults (38% v 44.8%). Staff smokers had higher odds than smokers in their communities of ever trying to quit (odds ratio [OR], 2.1; 95% CI, 1.1–3.7), of having often noticed anti-smoking advertising (OR, 2.8; 95% CI, 1.4–5.6), and of having used stop-smoking medications (OR, 3.0; 95% CI, 1.6–5.7), often with the support of their ACCHS. There was a significant association (P < 0.001) between the smoking status of Aboriginal and Torres Strait Islander staff and their confidence in talking to others about smoking and quitting; ex-smokers were most likely to report being confident. Most Aboriginal and Torres Strait Islander staff who smoked (74%) agreed that being a non-smoker sets a good example to patients at their health service, and most did not smoke with patients or at work where patients could see them. Conclusion: Smoking prevalence among Aboriginal and Torres Strait Islander ACCHS staff is only modestly lower than among other employed Aboriginal and Torres Strait Islander people. Given that ex-smokers feel more confident to help others quit than any other group, smoking cessation in ACCHS staff is a useful contributor to reducing community smoking rates.

David P Thomas MB BS, PhD, FAFPHM · Maureen E Davey MB BS, FAFPHM · Kathryn S Panaretto MB BS, MPH, FAFPHM · Jennifer M Hunt MPH, FAFPHM, PhD · Matthew Stevens PhD, BSc(Hons) · Anke E van der Sterren MPH, MA, BA

PAT ANDERSON, chair of the Lowitja Institute, Australia's National Institute for Aboriginal and Torres Strait Islander Health Research, provides generous praise to the authors of this work for their valuable contribution to research and practice of empowerment in Aboriginal health (http://www.lowitja.org.au/promoting-aboriginal-health-family-wellbeing-empowerment-approach). When you read this text you will find that the praise is well deserved. However, it would have been handy if it had also ...

Dameyon Bonson