A study of the use of free nicotine patches by Indigenous people

OBJECTIVE: To assess use of free nicotine patches by Indigenous people when offered a brief intervention for smoking cessation, and to assess changes in smoking behaviour at six months. METHODS: We conducted a pre and post study in three Indigenous communities in the Northern Territory. RESULTS: Forty Indigenous smokers self-selected to receive free nicotine patches and a brief intervention for smoking cessation, and 71 chose the brief intervention only. Eighty-four per cent of participants were followed up; 14% of participants could not be located. Fifteen per cent of the nicotine patches group (10% with CO validation) and 1% (CO validated) of the brief intervention only group reported that they had quit at six months. Seventy-six per cent of the nicotine patches group and 51% of the brief intervention only group had reduced their consumption of tobacco. No participant completed a full course of patches. One possible side effect--the experience of bad dreams--was attributed in one community to the person concerned having been 'sung' or cursed. CONCLUSIONS: Free nicotine patches might benefit a small number of Indigenous smokers. Cessation rates for the use of both nicotine patches and brief intervention alone were lower than those in other populations, possibly because the study was conducted in a primary care setting and because of barriers to cessation such as widespread use of tobacco in these communities and the perception of tobacco use as non-problematic.     

Translation of tobacco policy into practice in disadvantaged and marginalized subpopulations: a study of challenges and opportunities in remote Australian Indigenous communities

Background

In Australia generally, smoking prevalence more than halved after 1980 and recently commenced to decline among Australia's disadvantaged Indigenous peoples. However, in some remote Indigenous Australian communities in the Northern Territory (NT), extremely high rates of up to 83% have not changed over the past 25?years. The World Health Organisation has called for public health and political leadership to address a global tobacco epidemic. For Indigenous Australians, unprecedented policies aim to overcome disadvantage and close the 'health gap' with reducing tobacco use the top priority. This study identifies challenges and opportunities to implementing these important new tobacco initiatives in remote Indigenous communities. Methods: With little empirical evidence available, we interviewed 82 key stakeholders across the NT representing operational- and management-level service providers, local Indigenous and non-Indigenous participants to identify challenges and opportunities for translating new policies into successful tobacco interventions. Data were analysed using qualitative approaches to identify emergent themes.

Results

The 20 emergent themes were classified using counts of occasions each theme occurred in the transcribed data as challenge or opportunity. The 'smoke-free policies' theme occurred most frequently as opportunity but infrequently as challenge while 'health workforce capacity' occurred most frequently as challenge but less frequently as opportunity, suggesting that policy implementation is constrained by lack of a skilled workforce. 'Smoking cessation support' occurred frequently as opportunity but also frequently as challenge suggesting that support for individuals requires additional input and attention.

Conclusions

These results from interviews with local and operational-level participants indicate that current tobacco policies in Australia targeting Indigenous smoking are sound and comprehensive. However, for remote Indigenous Australian communities, local and operational-level participants' views point to an 'implementation gap'. Their views should be heard because they are in a position to provide practical recommendations for effective policy implementation faithful to its design, thereby translating sound policy into meaningful action. Some recommendations may also find a place in culturally diverse low- and middle-income countries. Key words: tobacco policy implementation, challenges, opportunities, remote Indigenous Australian communities.     

National trends in Aboriginal and Torres Strait Islander smoking and quitting, 1994-2008

Objective: To describe the trends in the prevalence of smoking, quitting and initiation among Aboriginal and Torres Strait Islander men and women aged 18 years and over. Methods: Analysis of responses to smoking questions in national Indigenous surveys in 1994, 2002, 2004 and 2008. Results: Male Indigenous smoking prevalence fell significantly from 58.5% in 1994 to 52.6% in 2008, an absolute decrease of 0.4 (CI 0.1–0.7)% per year, with the same decline in remote and non‐remote areas. Female smoking fell from 51.0% to 47.4%, with markedly different changes in remote and non‐remote areas. In non‐remote areas, there was an absolute decrease in female smoking of 0.5 (CI 0.2–0.9)% per year, but in remote areas, female smoking increased by 0.4 (CI 0.0–0.8)% per year. From 2002 to 2008, the percentage of ever‐smokers who had quit (quit ratio) increased absolutely by 1% per year in both men and women, remote and non‐remote areas. Results about trends in initiation were inconclusive. Conclusions and Implications: Health Minister Roxon has committed to halving the Indigenous smoking prevalence by 2018, and has dramatically increased Indigenous‐specific funding and activity in tobacco control. The reported historical trends in this paper are encouraging as they occurred at a time when there was little such tobacco control activity focused on Aboriginal and Torres Strait Islander people. However, to meet the Minister's goal, Indigenous smoking prevalence will need to fall more than six times as quickly as occurred from 1994 to 2008.     

How do trends in smoking prevalence among Indigenous and non‐Indigenous Australian secondary students between 1996 and 2005 compare?

Objective: To compare trends in smoking prevalence between 1996 and 2005 among Indigenous and non-Indigenous secondary students across Australia.
Methods: Representative random samples of secondary students aged 12-17 years completed self-report anonymous surveys. Questionnaires assessed any cigarette smoking in lifetime, and smoking in past month, week and on at least three of the previous seven days. Intention to smoke in the next 12 months was assessed on a 7-point scale. Students self-identified as being of Aboriginal or Torres Strait Islander descent.
Results: Three to four per cent of students identified as being Indigenous at each survey. Smoking was more common among Indigenous than non-Indigenous students. Between 1996 and 2005, the proportion of smoking declined among both Indigenous and non-Indigenous students. However, among 12-15 year olds, the rate of decline was different for the two groups. Among non-Indigenous students in this age group, prevalence decreased steadily between 1996 and 2005. Among Indigenous students, the decrease mainly occurred between 1999 and 2002. Smoking intention was higher for Indigenous than non-Indigenous students. The mean intention decreased between 1996 and 2005 among both student groups.
Conclusions: Smoking prevalence decreased among both Indigenous and non-Indigenous students between 1996 and 2005.
Implications: Reductions in Indigenous students' tobacco use and intentions coincided with a period of increased tobacco control activity, suggesting that these activities may positively influence smoking behaviours.     

Monitoring local trends in Indigenous tobacco consumption

Objective : To compare two methods of monitoring tobacco consumption in remote Indigenous communities.
Methods : We examined the monthly difference between wholesale invoice and point-of-sale data for tobacco products from three stores from remote Aboriginal communities in the Northern Territory. We assessed three measures of wholesale data.
Results : The average monthly difference between the sale data and the average of wholesale invoices for the previous, same and following month was -33 cigarettes per day (95% CI -157, 92). This average of three months' wholesale invoices provided a more precise estimate than either wholesale invoices from the same or previous month.
Conclusion : Tobacco wholesale data provided a close estimate of sales data in these stores.
Implications : This wholesale data could be used to monitor local trends in remote Indigenous tobacco consumption, facilitating the evaluation of the impact of tobacco control activities and informing future work to reduce Indigenous smoking and its harms.     

Tobacco cessation in adolescent females in Appalachian communities

Adolescents who live in tobacco-growing areas use tobacco at earlier ages and more frequently than other youth. These adolescents, like all tobacco users, have many health risks. To be successful, cessation efforts targeting these youth must reflect the cultural, social, and economic import of tobacco in their communities. Six focus groups with girls aged 12 to 14 who lived in tobacco-growing communities in Appalachian Ohio, Tennessee, and Virginia and 20 interviews with key informants were conducted. Barriers identified by informants included community norms around tobacco use, family use of tobacco, school practices and policies, peer influences, youth attitudes, and logistical difficulties with cessation program efforts. Key findings indicated: (1) the social community in tobacco-growing communities is a significant influence in tobacco use; (2) family is important among young people in tobacco-growing communities and influences cessation positively and negatively; (3) parental smoking was an influence to smoke (4) some parents condone and even facilitate tobacco use by their children, but others actively discourage use; and (5) concern for the health of younger brothers and sisters elicits a strongly protective reaction from youth in discussions of health risks related to secondhand smoke. Youth in tobacco-growing regions have many similarities to others, but they also have unique cultural characteristics pertinent in the development and delivery of tobacco cessation programs.     

天津市居民吸烟及戒烟状况调查分析

目的：了解天津市居民吸烟状况、戒烟想法及戒烟方法的应用,为有针对性地在居民中开展健康教育活动提供依据,同时为制定相关控烟政策提供基础数据。方法使用 PPS 法(按规模大小成比例的概率抽样)在每个区抽取3个街道,共计16个区。使用 PPS 在每个街道抽取2个居委会抽样单位,采用随机抽样方法在每个居委会抽取70个家庭户,每个家庭户采用 KISH 表抽取1名调查对象,每个居委会完成50份调查问卷。结果男性现在吸烟率为42.35%,女性现在吸烟率为10.32%,男性吸烟率高于女性(χ2=760.956,P <0.05),不同文化程度居民吸烟率差异有统计学意义(χ2=95.605,P <0.05)。男性与女性现在吸烟者戒烟意愿差异无统计学意义(χ2=2.959,P >0.05),不同吸烟量的现在吸烟者戒烟意愿差异有统计学意义(χ2=30.434,P <0.05),随着吸烟者吸烟量的增大,想戒烟的比例也在逐渐降低。89.18%现在吸烟者选择靠自己毅力戒烟,7.06%选择拨打戒烟热线。在过去12个月,有42.25%医护人员建议吸烟者戒烟。非吸烟者对主动吸烟及吸入二手烟的危害知晓率高于吸烟者,有戒烟想法的人主动吸烟及吸入二手烟的危害知晓率高于吸烟者。结论应积极开展控烟工作,有针对性地对男性、女性吸烟者开展控烟干预工作,加大戒烟门诊、戒烟热线的宣传,提高医务人员的戒烟知识和戒烟技巧,广泛宣传主动吸烟与被动吸烟的危害,同时政府部门加强控烟法律执行力度,保证人民群众不受二手烟的危害。     

Trachoma surveillance in Australia, 2009. A report by the National Trachoma Surveillance and Reporting Unit

Trachoma is highly prevalent in remote Indigenous communities in Australia. The National Trachoma Surveillance and Reporting Unit was established in 2006 as a result of a Federal Government initiative to provide comprehensive surveillance data from regional and remote Indigenous communities considered by the jurisdictional population health staff to be 'At Risk' for endemic trachoma, defined as a trachoma prevalence of 5% or more. This report details the findings from the 2009 trachoma screening program together with trends in trachoma prevalence and screening coverage since 2006. Aboriginal children aged 1-9 years resident in At Risk communities were examined for trachoma using the World Health Organization (WHO) simplified trachoma grading criteria. In the Northern Territory, screening was conducted by staff from the Healthy School Age Kids program and the Aboriginal Community Controlled Health Services. In South Australia, screening was conducted by the Eye Health and Chronic Disease Specialist Support Program and a team of visiting ophthalmologists and optometrists. In Western Australia, screening was conducted by staff from State Government population health units and Aboriginal Community Controlled Health Services. In the Northern Territory, 53 of 86 At Risk communities were screened and data were reported for 2283 children. In South Australia, 12 of 72 At Risk communities were screened and data were reported for 149 children. In Western Australia, 68 of 74 At Risk communities were screened and data were reported for 1684 children. The prevalence of active trachoma ranged from 1%-44% in the Northern Territory, 0%-57% in South Australia and 13%-15% in Western Australia. Trend analysis across all three jurisdictions combined found that neither the prevalence of trachoma nor community screening coverage changed significantly between 2006 and 2009. When trend analysis was "done by jurisdiction, there was a significant decrease in trachoma prevalence and a significant increase in community screening coverage only for Western Australia over the same 4 year period. The implementation of the and Environmental improvement (SAFE) strategy has been variable. Surgery referral processes for trichiasis were reported as available in all screened communities in the Northern Territory and South Australia but only in 35% of screened communities in Western Australia. Antibiotics were distributed according to Communicable Diseases Network Australia guidelines in 89% of communities where treatment was indicated. Facial cleanliness programs and resources were reported as poorly implemented in South Australia and Western Australia while minimal data were reported for environmental conditions in all jurisdictions. No significant change was found in bacterial resistance to azithromycin from 2007 to 2009. Significant gaps remain in community screening coverage and in the full implementation of the SAFE strategy. However, the parallel increase in community screening coverage and decrease in trachoma prevalence in Western Australia suggests that the SAFE strategy might have had an effect in reducing trachoma prevalence in that jurisdiction.     

'I don't want to be in that big city; this is my country here': research findings on Aboriginal peoples' preference to die at home

OBJECTIVE: The present article provides findings from a two-year study on Indigenous palliative care conducted in the Northern Territory that explored and documented wishes in relation to place of death for rural and remote Aboriginal people. DESIGN: Qualitative, open-ended interviews, audio-recorded, transcribed verbatim, and thematically analysed. PARTICIPANTS: There were a total of 72 interviews completed with Indigenous patients (n = 10), Indigenous caregivers (n = 19), Indigenous and non-Indigenous health care workers (n = 41), and interpreters (n = 2). RESULTS: The findings provide a clear articulation of the wish of Aboriginal people from rural and remote areas to die at home connected to land and family. Strong cultural reasons were given for this preference, including the strong connection with land and community, a belief in 'death country', the importance of passing on sacred knowledge to the appropriate family member, the significance of ensuring that the dying individual's 'animal spirit' is able to return to the land, and the imperative that the 'right person' in the family network is available to provide the care. CONCLUSION: The strong wish to die at home informs the importance of building up local health and palliative care services and avoiding, where possible, the need for relocation for health care to the major metropolitan hospitals during end-of-life care.     

Supporting Pregnant Aboriginal and Torres Strait Islander Women to Quit Smoking: Views of Antenatal Care Providers and Pregnant Indigenous Women

To assess support for 12 potential smoking cessation strategies among pregnant Australian Indigenous women and their antenatal care providers. Cross-sectional surveys of staff and women in antenatal services providing care for Indigenous women in the Northern Territory and New South Wales, Australia. Respondents were asked to indicate the extent to which each of a list of possible strategies would be helpful in supporting pregnant Indigenous women to quit smoking. Current smokers (n = 121) were less positive about the potential effectiveness of most of the 12 strategies than the providers (n = 127). For example, family support was considered helpful by 64 % of smokers and 91 % of providers; between 56 and 62 % of smokers considered advice and support from midwives, doctors or Aboriginal Health Workers likely to be helpful, compared to 85–90 % of providers. Rewards for quitting were considered helpful by 63 % of smokers and 56 % of providers, with smokers rating them more highly and providers rating them lower, than most other strategies. Quitline was least popular for both. This study is the first to explore views of pregnant Australian Indigenous women and their antenatal care providers on strategies to support smoking cessation. It has identified strategies which are acceptable to both providers and Indigenous women, and therefore have potential for implementation in routine care. Further research to explore their feasibility in real world settings, uptake by pregnant women and actual impact on smoking outcomes is urgently needed given the high prevalence of smoking among pregnant Indigenous women.     

Lukumbat marawana: a changing pattern of drug use by youth in a remote Aboriginal community

Objective: To examine marijuana use by youth in a remote Aboriginal community in Northern Australia over a 5‐year period. Design: Participant observation, structured and unstructured interviews. Setting: Remote Indigenous Australian community. Participants: Young Aboriginal people and adult community members. Main outcome measure: Emergent themes of the attitudes towards marijuana use among remote Indigenous residents are reported. Results: Restrictions in the availability of alcohol and petrol have led to increased use of marijuana with serious social and community consequences. Conclusions: Efforts to control licit substances, such as alcohol, in remote communities need to be addressed in the context of understanding of the dynamics of alcohol and drug use in totality as well as interventions that address underlying structural and social inequalities.     

Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people

Tobacco smoking has been identified as a major contributor to the high morbidity and mortality rates of Aborigines and Torres Strait Islanders. After years of inattention, smoking cessation projects designed for Indigenous Australians are beginning to emerge. Dealing successfully with smoking cessation would be enhanced by an understanding of the long-standing historical, social and cultural antecedents to present-day usage of tobacco. This paper provides a brief account of the historical precursors to present-day patterns of tobacco use among Aboriginal and Torres Strait Islander people. Historical records and mission documents, together with ethnographic accounts, suggest that Indigenous tobacco use today demonstrates strong continuity with past patterns and styles of use. These sources also reveal that Europeans deliberately exploited Aboriginal addiction to nicotine.     

The social determinants of being an Indigenous non-smoker

OBJECTIVE: To examine the association between various social factors and being a non-smoker in a national survey of Aboriginal and Torres Strait Islander people aged 15 and over. METHODS: We analysed data from the 2002 National Aboriginal and Torres Strait Islander Social Survey (n=9,400) using logistic regression. RESULTS: About a half (51.2%) of the Aboriginal and Torres Strait Islander population aged 15 years and over smoked, 33.4% had never smoked, and 15.4% were ex-smokers. Higher socio-economic position (as measured by each of nine variables) was strongly associated with being a non-smoker rather than a smoker, after controlling for age and gender. There was a clear income gradient: increasing household income was associated with increasing likelihood of being a non-smoker. Indigenous people who had been arrested in the last five years were 4.5 times less likely to be non-smokers, adjusted for age and gender. Indigenous people who had been removed from their natural family were half as likely to be a non-smoker. CONCLUSIONS: Different groups within the Indigenous population have quite different smoking behaviours, although the prevalence of smoking is very high in all groups. The poorest and most socially disadvantaged are the least likely to be non-smokers. IMPLICATIONS: Indigenous tobacco control programs need to consider additional targeting of more disadvantaged groups. Tobacco control programs should work with broader campaigns to ameliorate social disadvantage among Indigenous peoples.     

西安市流动人口吸烟行为及认知的现况调查

目的：了解西安市流动人口吸烟行为及认知现状,为进一步的控烟干预提供理论依据。方法对西安市1222名流动人口进行统一的问卷调查,描述其吸烟及认知现状,并对不同特征人群吸烟及认知情况进行比较分析。结果西安市流动人口吸烟率为43.9%,男性明显高于女性（P〈0.01）;不同年龄、不同文化程度、不同住房类型、当地是否单独生活、每天工作时间和是否倒班人群间吸烟率均具有统计学差异（P〈0.05）;现在吸烟率15.2%;接触二手烟的比例为82.6%,吸烟危害健康知识知晓率为4.0%,接触二手烟危害健康知识知晓率为9.5%。不同文化程度人群对吸烟危害以及不同吸烟行为、性别、文化程度人群对二手烟危害的知晓率有统计学差异（P〈0.05）。不同吸烟行为人群对吸烟相关观点的态度持有率存在统计学差异（P〈0.05）。结论西安市流动人口吸烟率高,认知水平低,应针对流动人口吸烟的人群特征分布,制定控烟干预政策,从而减少烟草对流动人口的健康危害。     

Clear not simple: an approach to community consultation for a maternal pneumococcal vaccine trial among Indigenous women in the Northern Territory of Australia

PneuMum is a randomised controlled maternal vaccination trial, using 23-valent Pneumococcal Polysaccharide Vaccine (23vPPV) during the third trimester or at delivery compared to vaccination at 7 months post delivery. The primary outcomes are infant middle ear disease and nasopharyngeal pneumococcal carriage at 7 months of age. PneuMum is the first vaccine trial to be conducted among Indigenous people in the Northern Territory. We describe the study design and the approach taken to develop the PneuMum message in collaboration with key Indigenous stakeholders and then to communicate the PneuMum message with Indigenous communities and potential participants. We hope that these methods will provide a model for future research involving Indigenous communities to ensure Indigenous involvement in research and ultimate improvements in Indigenous health.     

Orientation for general practice in remote Aboriginal communities: a program for registrars in the Northern Territory

BACKGROUND: Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers. OBJECTIVES: This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context. DISCUSSION: Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.