Stressful life events, resources, and access: key considerations in quitting smoking at an Aboriginal Medical Service

OBJECTIVE: Aboriginal and Torres Strait Islander people experience adverse health outcomes and have high rates of smoking and related illnesses. This brief report describes stress as a barrier to quitting smoking derived from reflections within an Aboriginal Medical Service and makes recommendations for intervention development. METHODS: A high-intensity smoking cessation program was conducted within a suburban Aboriginal Medical Service in Western Sydney, Australia, over a 10-month period. The intervention included weekly cessation counselling sessions and dispensation of free nicotine replacement therapy (NRT). RESULTS: During the observation period, 32 clients made quit attempts. To date, three clients (9%) have quit smoking. Chronic and intercurrent life stressors were noted to be the main barriers to smoking cessation described by participants. CONCLUSIONS: Achieving smoking cessation among Indigenous people is made significantly more complex because of multiple life stressors experienced. IMPLICATIONS: Future interventions targeting Indigenous Australians should take greater account of stressful life events and their impact on quitting smoking.     

Quitting smoking and experience of smoking cessation interventions among UK Bangladeshi and Pakistani adults: the views of community members and health professionals

OBJECTIVE: To explore attitudes to quitting smoking and experience of smoking cessation among Bangladeshi and Pakistani ethnic minority communities. DESIGN: Qualitative study using community participatory methods, purposeful sampling, interviews and focus groups, and a grounded approach to data generation and analysis. SETTING: Newcastle upon Tyne, UK, 2000-2002. PARTICIPANTS: 53 men and 20 women aged 18-80 years, including smokers, former smokers, and smokers' relatives, from the Bangladeshi and Pakistani communities; and eight health professionals working with these communities. RESULTS: Motivation to quit was high but most attempts had failed. "Willpower" was the most common approach to quitting. For some, the holy month of Ramadan was used as an incentive, however few had been successful in quitting. Perceived barriers to success included being tempted by others, everyday stresses, and withdrawal symptoms. Few participants had sought advice from health services, or received cessation aids, such as nicotine replacement therapy (NRT) or buproprion. Family doctors were not viewed as accessible sources of advice on quitting. Health professionals and community members identified common barriers to accessing effective smoking cessation, including: language, religion and culture; negative attitudes to services; and lack of time and resources for professionals to develop necessary skills. CONCLUSIONS: High levels of motivation do not seem to be matched by effective interventions or successful attempts to quit smoking among Bangladeshi and Pakistani adults in the UK. There is a need to adapt and test effective smoking cessation interventions to make them culturally acceptable to ethnic minority communities. UK tobacco control policies need to give special attention to the needs of ethnic minority groups.     

Predictors of intention to quit smoking among Jordanian university students

PURPOSE: To identify predictors that influence tobacco smoking cessation among Jordanian college students and to test the utility of the Trans-Theoretical Model for future cessation programs in this population. METHOD: A cross-sectional survey of randomly selected college students (18 to 22 years of age) who were smokers was conducted at two Jordanian universities. The surveys included the: Tobacco Use Questionnaire; Tobacco Use Self-Efficacy; Rosenberg Self-Esteem Scale; Barriers to Cessation; and the Fagerstrom Tobacco Nicotine Dependency Scale. Due to the complex nature of the contextual and individual factors related to smoking behaviour, a structural equation modeling approach was used to identify variables that may influence participation in tobacco smoking cessation programs. RESULTS: There was a 75% response rate with a total of 800 students (90% male) completing the survey. Three factors were identified as major contributors toward quitting smoking: a) a high stage of readiness, b) previous experience with barriers to smoking cessation, and c) past experience with quitting. CONCLUSIONS: The findings suggest that the value of smoking cessation programs should not be measured on recidivism rates alone. The implications are that such programs should make return to treatment easy and as guilt free as possible to improve ultimate long-term smoking abstinence.     

Tobacco cessation in Vietnam: Exploring the role of village health workers

The purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre’s smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.     

Increasing access to evidence-based smoking cessation treatment: effectiveness of a free nicotine patch program among Chinese immigrants

Pharmacotherapy substantially increases smoking cessation rates. However, programs to reduce barriers to this evidence-based treatment may not improve access among high risk immigrant non English speaking populations. This study estimates the effectiveness of a tailored free nicotine patch (NRT) program among Chinese American smokers living in New York City (NYC). Between July 2004 and May 2005 NRT was distributed to 375 smokers through two community-based organizations that serve the Asian American population in NYC. Participants completed an in person baseline survey and a 4-month follow-up telephone survey. Using an intention to treat analysis the abstinence rate at 4 months was 26.7% (100/375). Predictors of cessation included higher levels of self efficacy at baseline, not smoking while using the patch and concern about personal health risks. Distribution through easy to access, culturally competent local community organizations increased the reach of a free nicotine patch program and assisted smokers in quitting.     

Internet-Based Smoking Cessation Initiatives

Tobacco use remains widespread in every nation in the world. Worldwide, >1.3 billion people use tobacco products. Many smokers who attempt to quit need cessation assistance such as education, motivation, counseling, and pharmacologic treatments, but many lack access to these resources because of geographic isolation, economic constraints, and cultural barriers. As global Internet use continues to grow, Internet-based smoking cessation programs are a promising strategy for reaching smokers worldwide.The purpose of this article is to examine Internet-based initiatives to assist smokers to quit. The advantages and disadvantages of this type of forum, the likely effectiveness in achieving smoking cessation, and the impact on clinical and cost outcomes are discussed. The primary advantage of Internet-based smoking cessation initiatives is their potential public health reach. Disadvantages include the potential for privacy and security breaches, concerns about inferior quality of information, and failure of websites to utilize online technologies.Internet-based smoking cessation programs can extend the clinical encounter, in essence allowing the provider to offer ‘virtual’ support to the patient who is attempting to quit smoking. The potential of Internet technology to reach large numbers of smokers and provide reliable information for quitting is only beginning to be realized. Few studies have rigorously examined the question of efficacy, and many questions remain unanswered.To illustrate the important features of Internet-based smoking cessation initiatives, this review evaluated existing online programs. A smoking cessation program was defined as a structured, multi-component treatment plan specifically designed to aid in quitting. Twelve websites were identified from an Internet search (using an Internet search engine) that met our criteria. The interactive capabilities of Internet applications show great promise for customizing a smoking cessation plan ‘on-the-fly’ for individuals seeking support in quitting, but few websites offer programs that incorporate tailored approaches. Thus, patients should look to healthcare providers to help them understand the benefits and limitations of Internet-based information resources for smoking cessation.     

Reducing racism in Aboriginal health care in Australia: where does cultural education fit?

Objective : This paper discusses whether educating health professionals and undergraduate students in culturally respectful health service delivery is effective in reducing racism, improving practice and lessening the disparities in health care between Aboriginal and non‐Aboriginal Australians. Approach : The paper supports the concept of race as a social construction that is discursively produced and reproduced. Studies on the effectiveness of cross‐cultural education for undergraduate students and health professionals to reduce racism and deliver culturally respectful health care to indigenous or minority populations are examined for evidence of sustained improvements to practice. Conclusion : Programs in culturally respectful health care delivery can lead to short‐term improvements to practice. Sustained change is more elusive as few programs conducted long‐term evaluations. Long‐term evaluation of programs in culturally respectful health care delivery is necessary to identify whether early changes to behavior and practices are sustained. Strategies linking policies to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians are also needed. Implications : Confronting the effects of racism in health services towards Aboriginal Australians is a priority requiring a multi‐tiered commitment to strategies linking policy to practice to reduce health disparities between Aboriginal and non‐Aboriginal Australians. Part of this strategy includes preparing undergraduates and health professionals for culturally respectful health care with education programs that are evaluated for long‐term improvements to practice.     

Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa

Objective: Access barriers to health care for minority populations has been a feature of medical, health and social science literature for over a decade. Considerations of cultural barriers have featured in this literature, but definitions of what constitutes a cultural barrier have varied. In this paper, data from recent interviews with Aboriginal and Torres Strait Islander people, Aboriginal Health Workers and other non‐Indigenous health professionals in north‐west Queensland assist to refine the meaning of this term and uncovered other issues disguised as ‘cultural’ difference. Design: Semistructured interviews with community and health professionals. Setting: Mount Isa, Queensland, Australia. Participants: Aboriginal and Torres Strait Islanders, Aboriginal Health Workers and other health professionals in Mount Isa between 2007 and 2009. Results: Cultural barriers were considered differently by Aboriginal patients and health practitioners. While Aboriginal patients focused heavily on social relationships and issues of respect and trust, most practitioners seemed more focused on making Aboriginal people feel comfortable with changes to physical environments and systems, with less emphasis on creating strong interpersonal relationships. Conclusions: For Aboriginal patients the focus on interpersonal relationships between themselves and health practitioners is paramount. Creating comforting physical environments and systems that are easier to navigate do assist in overcoming cultural barriers, but are often seen as little more than token gestures if trusting interpersonal relationships are not formed between patient and practitioner.     

In search of a healing place: Aboriginal women in Vancouver's Downtown Eastside

Research on general health service delivery in urban areas of Canada shows that Aboriginal people face formidable barriers in accessing culturally appropriate and timely care. Over the past decade, Urban Aboriginal Health Centres (UAHCs) have emerged to address the unmet health concerns of Aboriginal people living in metropolitan areas of the country. The purpose of this research was to address the gap in social science literature on how the health care concerns of Aboriginal women are being met by UAHCs. The research aimed to give voice to Aboriginal women by asking them whether the appropriate professional services and educational programs they need to address their health care needs were being provided in the inner city. A case-study approach was used whereby three separate focus groups were conducted with Aboriginal women who were clients of the Vancouver Native Health Society (VNHS), its sister organization, Sheway, or residents of Vancouver's Downtown Eastside (DTES). In addition, twenty-five semi-structured interviews were conducted with VNHS staff, health providers, government representatives, and community leaders in health care (total n=61). The findings indicate that despite efforts from various quarters to articulate the health and social concerns of the country's marginalized populations, such has not been the case for Aboriginal women living in one of Canada's most prosperous cities. Many Aboriginal women expressed a strong desire for a Healing Place, based on a model of care where their health concerns are addressed in an integrated manner, where they are respected and given the opportunity to shape and influence decision-making about services that impact their own healing.     

Chronic disease prevention programs offered by Aboriginal Community Controlled Health Services in New South Wales,Australia

Objectives : To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia. Methods : ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised. Results : We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration. Conclusions : Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one‐quarter are time‐limited. Implications for public health : Chronic disease programs that are co‐produced with specific groups, based on age and gender, may be needed.     

Factors influencing the willingness of community service organisation staff to provide smoking cessation support: a qualitative study

Objective : This study aimed to explore factors influencing community service organisation (CSO) staff members’ willingness to provide tobacco cessation support to clients experiencing disadvantage. Methods : Face‐to‐face semi‐structured interviews were conducted with 29 staff members from seven services in the alcohol and other drugs, homelessness, and mental health sectors in Western Australia. Results : The primary barriers to providing cessation support were believing that addressing smoking was not a priority relative to other issues, being a current smoker, and the lack of a formal tobacco cessation program within the organisation. Factors that appeared to be most influential in enabling the delivery of cessation support were organisational processes requiring staff to routinely ask clients about tobacco use, confidence to provide support, and being a past smoker. Conclusions : The introduction of organisational procedures that include routine cessation care should be of high priority in CSOs to help reduce smoking rates among clients. Staff may also benefit from receiving training in the provision of cessation support and education about the importance and feasibility of addressing smoking concurrently with other issues. Implications for public health : The results may inform future efforts to increase the delivery of cessation care to groups of people experiencing disadvantage and comorbidity.     

Association between age, gender and reasons for smoking cessation

AIMS: To contribute to improved programs for smoking cessation, the authors wanted to assess the relationships between age, gender and ex-smokers' quitting reasons and examine predictors of the most commonly reported quitting reasons. METHODS: A questionnaire was mailed to 11,919 subjects in Akershus County, Norway. Among the 7,697 respondents (65%), self-reported reasons for smoking cessation in 1,715 ex-smokers were analysed. Using cross-tables and multivariate logistic regression, associations between age, gender, and reported quitting reasons were examined. RESULTS: Men were more likely to have stopped smoking to improve physical fitness, or out of consideration for other family members than the children, and less likely to have quit out of consideration for their own children, or in solidarity with a spouse that stopped smoking. In multivariate logistic regression analysis, age was a predictor of all seven most common reasons to quit smoking. Gender, education, and the physical component of health status each predicted three of the seven quitting reasons. CONCLUSIONS: In the study sample, differences in smoking cessation behavior and reported quitting reasons were found according to both age and gender. Smoking cessation programs should be tailored to the relevant target groups, including stratification according to age and gender.     

Helping Smokers Quit: Understanding the Barriers to Utilization of Smoking Cessation Services

Context: Counseling smokers to quit smoking and providing them with pharmaceutical cessation aides are among the most beneficial and cost‐effective interventions that clinicians can offer patients. Yet assistance with quitting is not universally covered by health plans or offered by all clinicians. Analysis of stakeholders' perspectives and interests can identify the barriers to more widespread provision of cessation services and suggest strategies for the public policy agenda to advance smoking cessation. Methods: Review of literature and discussions with representatives of stakeholders. Findings: All stakeholders—health plans, employers, clinicians, smokers, and the government—face barriers to broader smoking cessation activities. These range from health plans' perceiving that covering counseling and pharmacotherapy will increase costs without producing commensurate health care savings, to clinicians' feeling unprepared and uncompensated for counseling. Like other preventive measures aimed at behavior, efforts directed at smoking cessation have marginal status among health care interventions. State governments can help correct this status by increasing Medicaid coverage of treatment and expanding coverage for state employees. The federal government can promote the adoption of six initiatives recommended by a government subcommittee on cessation: set up a national quit line, develop a media campaign to encourage cessation, include cessation benefits in all federally funded insurance plans, create a research infrastructure to improve cessation rates, develop a clinician training agenda, and create a fund to increase cessation activities through a new $2 per pack cigarette excise tax. Both the federal and state governments can increase cessation by adopting policies such as the higher cigarette tax and laws prohibiting smoking in workplaces and public places. Conclusions: Public policy efforts should assume greater social responsibility for smoking cessation, including more aggressive leadership at the state and federal levels, as well as through advocacy, public health, and clinician organizations.     

Barriers and facilitators for health professionals referring Aboriginal and Torres Strait Islander tobacco smokers to the Quitline

Objective: To examine the barriers and facilitators among health professionals to providing referrals to Quitline for Aboriginal and Torres Strait Islander clients who smoke. Methods: A brief online survey, based on the Theoretical Domains Framework, was completed by 34 health professionals who work with Aboriginal and Torres Strait Islander people in South Australia and the Northern Territory. Results: Respondents who frequently made referrals had higher domain scores than less frequent referrers for ‘Skills and knowledge’ (M=4.44 SD=0.39 vs. M=4.09 SD=0.47, p<0.05) and ‘beliefs about capabilities’ (M=4.33 SD=0.44 vs. M=3.88 SD=0.42, p<0.01). Barriers to providing referrals to Quitline were lack of client access to a phone, cost of a phone call, preference for face‐to‐face interventions, and low client motivation to quit. Conclusions: Health professionals working with Aboriginal and Torres Strait Islander clients should be supported to build their skills and confidence to provide referrals to Quitline and other brief cessation interventions. Building capacity for face‐to‐face support locally would be beneficial where phone support is not preferable. Implications for public health: Engaging with health professionals who work with Aboriginal and Torres Strait Islander people to increase referrals to Quitline is strategic as it builds on their existing capacity to provide cessation support.     

Psychologists and tobacco: attitudes to cessation counseling and patterns of use

BACKGROUND: Psychologists can play an important role in helping their clients stop using tobacco. The extent to which they do so, or quit themselves, has not been reported previously. The utility of snus in reducing smoking prevalence is also questioned and merits study. METHOD: A 36-item self-completion questionnaire was mailed to a random sample of 1000 Swedish psychologists. RESULTS: The response rate was 85%. Very few psychologists (1%) 'often' helped clients to stop using tobacco. While a majority (72%) believed that quitting tobacco use would improve their client's quality of life, most (75%) thought that it was not their responsibility to help clients stop and 74% felt they lacked the necessary skills. About 8% of psychologists smoked cigarettes daily. Use of snus as an aid to cigarette cessation was common in men, but not women, although overall, the percentage of smokers who had quit smoking (72%) did not differ by gender. CONCLUSIONS: Most Swedish psychologists have stopped smoking, but very few help their clients to quit. Targeted campaigns aimed at encouraging and supporting psychologists to treat nicotine dependence are needed. This could increase cessation rates in the population. Snus helped reduce smoking prevalence among men and is a potentially useful harm reduction tool.     

Understanding an Aboriginal and Torres Strait Islander child’s journey through paediatric care in Western Australia

Objective: To explore caregiver perspectives of their children’s journey through the specialist paediatric service, the Aboriginal Ambulatory Care Coordination Program (AACC), and non‐AACC services at the Perth Children’s Hospital. Methods: Eighteen semi‐structured interviews with families of Aboriginal children were completed. Indigenous research methodology and a phenomenological approach guided data collection and analysis. Results: Four key themes were identified from interviews: hospital admissions, discharge and follow‐up outpatient appointments; communication; financial burden; and cultural issues. Our findings suggest Aboriginal children and their caregivers using the AACC program had more positive and culturally secure experiences than those using non‐AACC services. However, barriers relating to health providers’ understanding of Aboriginal cultural issues and lived experience were commonly discussed, regardless of which service families received. Conclusions: Australian Aboriginal children have an increased use of tertiary hospital care compared to non‐Indigenous children. Healthcare programs specifically designed for Aboriginal children and their families can improve their experience of care in hospital. However, improvements in cultural awareness for other hospital staff is still needed. Implications for public health: Dedicated Aboriginal programs in mainstream services can successfully improve cultural care to their clients, which is fundamental to improving service delivery for families.     

Tobacco Use and Interest in Smoking Cessation Among Latinos Attending Community Health Fairs

Health fairs are vital for reaching underserved Latinos providing access to health services including smoking cessation. The purpose of this study is to describe tobacco use and interest in smoking cessation among Latino smokers attending community health fairs. We surveyed 262 self-identified Latinos attending health fairs; we assessed smoking behavior and attitudes of 53 (20.2%) current smokers. Smokers were mostly uninsured (98.1%), male (54.7%), recent immigrants (96.2%) with limited English proficiency (60.4% spoke Spanish at home), and were mainly light (86.3%) and nondaily (58.7%) smokers. Although most participants attempted to quit smoking at least once in the past year, only 5.0% of current smokers reported ever using cessation medication and 94.3% were unaware of free-telephone counseling. The majority of smokers were ready to quit within 30 days and were interested in participating in cessation programs. Health fairs provide a unique opportunity to address smoking cessation among underserved Latinos with limited knowledge of access to, and use of effective cessation services.     

Parents' and carers' views on factors contributing to the health and wellbeing of urban Aboriginal children

Objective : To identify and describe caregiver perspectives on factors important for the health and wellbeing of urban Aboriginal children. Methods : Caregivers of Aboriginal children participating in the Study of Environment on Aboriginal Resilience and Child Health (SEARCH) were asked to describe the single most important factor that would help their children to be healthy and well. Responses were analysed using thematic and content analysis. Results : Of the 626 carers in SEARCH, 425 (68%) provided a response. We identified 13 factors related to: loving family relationships, culturally competent healthcare, food security, active living, community services, education, social and emotional connectedness, safety, breaking cycles of disadvantage, housing availability and affordability, positive Aboriginal role models, strong culture, and carer wellbeing. Conclusions : Aligning with holistic concepts of health, caregivers believe that a broad range of child, family and environmental‐level factors are needed to ensure the health and wellbeing of Aboriginal children. Implications for public health : This study highlights the importance of providing public health initiatives that enable equal access to the social determinants of health for carers of Aboriginal children. Affordable and adequate housing, food security, culturally appropriate healthcare, and family and community connectedness remain critical areas for targeted initiatives.