Undergraduate dietetics programs do not support training students in smoking cessation

Although tobacco use is the leading contributor to death and disability in the United States, allied health professionals often lack knowledge of smoking cessation techniques. The objective of this study was to identify the extent to which undergraduate dietetics programs (referred to as didactic programs in dietetics [DPD]) teach about tobacco and smoking cessation interventions and also DPD directors' opinions regarding tobacco and smoking cessation in dietetics education. All DPD directors in the United States (n=231) were sent a questionnaire to assess programs' and directors' demographics, courses that included tobacco and smoking cessation education, and directors' opinions pertaining to tobacco and smoking cessation education. The response rate was 49% (n=113). On average, DPD directors did not agree that tobacco and smoking cessation education should be a formal part of undergraduate dietetics programs and that it is not as important as other content areas required of dietetics students. Just 37% of directors believed that a dietitian's job responsibility included educating patients on smoking cessation. Only 7% of DPD directors had formal education on smoking cessation and tobacco use, but 53% had formal education on behavior modification. More than half of DPD programs (56%) did not offer any courses that provided tobacco and smoking cessation education. These results indicate that most undergraduate dietetics programs do not incorporate tobacco and smoking cessation education in their curricula. Dietetics and other allied health educators could consider including smoking cessation education in their curricula to ensure that future health professionals can contribute to Healthy People 2010 objectives related to smoking cessation.     

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.     

Tobacco control in the Czech Republic

Main points of tobacco control measures in the country are mentioned: smoking prevalence among population and health professionals (both about one third), smoking cessation availability (about 70 smoking cessation clinics), education of health professionals, both pre- and post-gradual, public-oriented actions, advertising, tobacco prices, legislation, cigarette consumption, mortality.     

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.     

An evaluation of tobacco brief intervention training in three indigenous health care settings in north Queensland

OBJECTIVE: To evaluate the pilot phase of a tobacco brief intervention program in three Indigenous health care settings in rural and remote north Queensland. METHODS: A combination of in-depth interviews with health staff and managers and focus groups with health staff and consumers. RESULTS: The tobacco brief intervention initiative resulted in changes in clinical practice among health care workers in all three sites. Although health workers had reported routinely raising the issue of smoking in a variety of settings prior to the intervention, the training provided them with an additional opportunity to become more aware of new approaches to smoking cessation. Indigenous health workers in particular reported that their own attempts to give up smoking following the training had given them confidence and empathy in offering smoking cessation advice. However, the study found no evidence that anybody had actually given up smoking at six months following the intervention. Integration of brief intervention into routine clinical practice was constrained by organisational, interpersonal and other factors in the broader socioenvironmental context. CONCLUSIONS/IMPLICATIONS: While modest health gains may be possible through brief intervention, the potential effectiveness in Indigenous settings will be limited in the absence of broader strategies aimed at tackling community-identified health priorities such as alcohol misuse, violence, employment and education. Tobacco and other forms of lifestyle brief intervention need to be part of multi-level health strategies. Training in tobacco brief intervention should address both the Indigenous context and the needs of Indigenous health care workers.     

‘It had to be my choice’ Indigenous smoking cessation and negotiations of risk,resistance and resilience

While Australia is considered a world leader in tobacco control, smoking rates within the Aboriginal and Torres Strait Islander population have not declined at the same rate. This failure highlights an obvious shortcoming of mainstream anti-smoking efforts to effectively understand and engage with the socio-cultural context of Indigenous smoking and smoking cessation experiences. The purpose of this article is to explore the narrative accounts of 20 Indigenous ex-smokers within an urban community and determine the motivators and enablers for successful smoking cessation. Our findings indicated that health risk narratives and the associated social stigma produced through anti-smoking campaigns formed part of a broader apparatus of oppression among Indigenous people, often inspiring resistance and resentment rather than compliance. Instead, a significant life event and supportive relationships were the most useful predictors of successful smoking cessation acting as both a motivator and enabler to behavioural change. Indigenous smoking cessation narratives most commonly involved changing and reordering a person's life and identity and autonomy over this process was the critical building block to reclaiming control over nicotine addiction. Most promisingly, at an individual level, we found the important role that individual health professionals played in encouraging and supporting Indigenous smoking cessation through positive rather than punitive interactions. More broadly, our findings highlighted the central importance of resilience, empowerment and trust within health promotion practice.     

Substance misuse intervention research in remote Indigenous Australian communities since the NHMRC ‘Roadmap’

Objective : Describe program theories of substance misuse interventions with Aboriginal and Torres Strait Islander (Indigenous) Australians funded by the National Health and Medical Research Council (NHMRC) since the ‘Roadmap’ for Indigenous health. Methods : Projects funded 2003–2013 were categorised by intervention strategies. Realist concepts informed the program theory: intended resources and responses; influence of context on outcomes; explicit and implicit program assumptions. Results : Seven interventions were included. Three randomised controlled trials targeted tobacco using psychosocial interventions in primary health centres using the program theory: “Local Indigenous health workers extend and sustain the effects of conventional clinical brief intervention by engendering social and cultural resources”. Four pragmatic trials of multiple‐component, community‐based interventions using controlled, semi‐controlled or before‐and‐after designs used the program theory: “Discrete intervention components targeting locally defined substance misuse issues will activate latent capacities to create an environment that favours cessation.” Publications did not report clear effect, implementation fidelity or explicit mechanisms affecting participant thinking. Conclusions : Rigorous intervention designs built on ‘Roadmap’ principles neither reduced substance use in the populations studied nor identified transferable mechanisms for behaviour change. Implications for public health : Substance misuse impacts among Indigenous Australians remain severe. Theoretical mechanisms of behaviour change may improve intervention design.     

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective: Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods: Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results: We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions: Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health: Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.     

Effectiveness of smoking cessation interventions: review of evidence and implications for best practice in Australian health care settings

OBJECTIVE: To review the evidence of the effectiveness of various smoking cessation methods and appropriateness for use in Australian health care settings. METHODS: Cochrane and other existing reviews and meta-analyses of evidence were the basis for the review. Systematic literature searches were also conducted to identify relevant controlled trials published internationally between January 1999 and May 2002. The main inclusion criteria for studies were use of a controlled evaluation design and an outcome measure of continuous abstinence from smoking for at least five months. A three-tiered grading system for strength of evidence was used. RESULTS: Clinic and hospital systems to assess and document tobacco use and routine provision of cessation advice can double long-term quit rates. While brief intervention can achieve a significant effect at population level, at individual level there is a strong dose response between the number and length of sessions of tobacco cessation counselling and its effectiveness. Effective behavioural interventions can increase cessation rates by 50-100% compared with no intervention. Some pharmacotherapies are safe and also help to substantially increase cessation rates. CONCLUSIONS: Effective behavioural and pharmacological methods of tobacco cessation are available. IMPLICATIONS: Every smoker should be offered evidence-based advice and treatment to quit smoking. This includes pharmacotherapy, unless contra-indicated. Health professionals and health care settings can play a significant role in motivating and assisting smokers to quit.     

Enabling the NSW health workforce to provide evidence-based smoking-cessation advice through competency-based training delivered via video conferencing

Tobacco-related disease is estimated to cost the NSW health system more than $476 million in direct health care costs annually. Population-based smoking-cessation interventions, including brief intervention by health professionals, are effective and cost effective. As the prevalence of smoking in the general community declines, more highly dependent 'treatment-resistant' smokers may present a challenge to the health system. International guidelines recommend that health systems invest in training for health professionals in best practice smoking cessation. As part of the NSW Tobacco Action Plan 2005-2009, NSW Department of Health developed national competency standards in smoking cessation, designed learning and assessment materials and delivered training to more than 300 health professionals via video conference. Building the capacity of the NSW Health workforce to address smoking cessation as part of their routine practice is essential for addressing future challenges in tobacco control.     

A content analysis of television advertising for the Massachusetts Tobacco Control Program media campaign, 1993-1996.

Television advertising for the Massachusetts Tobacco Control Program (MTCP) was launched in 1993. The campaign's first three years were examined against an analytical framework based in behavioral change and communications theory. The most common focus in the 49 advertisements was tobacco industry practices, followed by health consequences for smokers and smoking prevention. Only one smoking prevention advertisement was targeted to children younger that age 13. Only four advertisements mentioned policy actions to reduce youth access or curtail exposure to environmental tobacco smoke. Only two advertisements listed the telephone number for the MTCP's smoking cessation program. The television campaign was uncoordinated with the MTCP's community-level programs.     

Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors

In Australia, tobacco smoking is more than twice as common among Indigenous people as non-Indigenous people. Some of the highest smoking rates in the country are in remote Indigenous communities in the Northern Territory of Australia. Owing to this high prevalence, tobacco use today is the single biggest contributing risk factor for excess morbidity and mortality among Indigenous Australians. Despite this, there is a lack of published research which qualitatively explores the social context of Indigenous smoking behaviour or of meanings and perceptions of smoking among Indigenous people. The aim of this study was to understand why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting. We conducted semi-structured interviews with a purposive sample of 25 Indigenous community members in two remote communities in the Northern Territory and 13 health staff. The results indicate that there is a complex interplay of historical, social, cultural, psychological and physiological factors which influence the smoking behaviours of Indigenous adults in these communities. In particular, the results signal the importance of the family and kin relations in determining smoking behaviours. While most community participants were influenced by family to initiate and continue to smoke, the health and well being of the family was also cited as a key driver of quit attempts. The results highlight the importance of attending to social and cultural context when designing tobacco control programs for this population. Specifically, this research supports the development of family-centred tobacco control interventions alongside wider policy initiatives to counter the normalisation of smoking and assist individuals to quit.     

Potential effectiveness of specific anti-smoking mass media advertisements among Australian Indigenous smokers

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) have more than twice the smoking prevalence of non-Indigenous Australians. Anti-smoking campaigns have demonstrated success in the general population but little is known about their impact among Indigenous people. A total of 143 Indigenous and a comparison group of 156 non-Indigenous smokers from South Australia were shown 10 anti-smoking advertisements representing a range of advertisements typically aired in Australia. Participants rated advertisements on a five-point Likert scale assessing factors including message acceptance and personalized effectiveness. On average, Indigenous people rated the mainstream advertisements higher than non-Indigenous people and were more likely to report that they provided new information. Advertisements with strong graphic imagery depicting the health effects of smoking were rated highest by Indigenous smokers. Advertisements featuring real people describing the serious health consequences of smoking received mixed responses. Those featuring an ill person were rated higher by Indigenous people than those featuring the family of the person affected by a smoking-related disease. With limited Indigenous-specific messages available and given the finite resources of most public health campaigns, exposure to mainstream strong graphic and emotive first-person narratives about the health effects of smoking are likely to be highly motivating for Indigenous smokers.     

Brief intervention resource kits for Indigenous Australians: generally evidence‐based,but missing important components

Objective : Little is known about the content and quality of brief intervention kits specifically targeting SNAP risk factors (smoking, poor nutrition, alcohol misuse or physical inactivity) among Indigenous Australians. This paper reviews the type and quality of these kits. Methods : Brief intervention kits were primarily identified by contacting 74 health‐related organisations in Australia between 1 February 2007 and 4 March 2007. Results : Ten brief intervention kits met inclusion criteria: four targeted smoking; three targeted alcohol; one targeted alcohol, smoking and other drugs; one targeted alcohol, other drugs and mental health; and one targeted all SNAP risk factors. Brief intervention kits were reviewed using criteria developed from clinical guidelines for SNAP risk factors and guidelines for evaluating health promotion resources. Three kits met all review criteria. Five kits were consistent with evidence‐based guidelines, but lacked a training package, patient education materials and/or behavioural change strategies. All kits used images and language identifiable with Indigenous Australia, however, their cultural appropriateness for Indigenous Australians remains unclear. Conclusions and implications : The specific content of the missing components should be guided by the best‐available evidence, such as established mechanisms for health care provider feedback to patients as a behaviour change strategy, as well as the needs and preferences of health care providers and patients.     

Delivering culturally appropriate residential rehabilitation for urban Indigenous Australians: a review of the challenges and opportunities

Objective: To review the challenges facing Indigenous and mainstream services in delivering residential rehabilitation services to Indigenous Australians, and explore opportunities to enhance outcomes. Methods: A literature review was conducted using keyword searches of databases, on‐line journals, articles, national papers, conference proceedings and reports from different organisations, with snowball follow‐up of relevant citations. Each article was assessed for quality using recognised criteria. Results: Despite debate about the effectiveness of mainstream residential alcohol rehabilitation treatment, most Indigenous Australians with harmful alcohol consumption who seek help have a strong preference for residential treatment. While there is a significant gap in the cultural appropriateness of mainstream services for Indigenous clients, Indigenous‐controlled residential organisations also face issues in service delivery. Limitations and inherent difficulties in rigorous evaluation processes further plague both areas of service provision. Conclusion: With inadequate evidence surrounding what constitutes ‘best practice’ for Indigenous clients in residential settings, more research is needed to investigate, evaluate and contribute to the further development of culturally appropriate models of best practice. In urban settings, a key area for innovation involves improving the capacity and quality of service delivery through effective inter‐agency partnerships between Indigenous and mainstream service providers.     

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.     

Tobacco and aboriginal people in NSW

Tobacco use is a major cause of morbidity and mortality for Aboriginal people in NSW. Few interventions to reduce the harm resulting from tobacco use have been developed specifically for this population. However, brief interventions for smoking cessation, pharmacotherapies such as nicotine replacement therapy, bupropion and varenicline, quit groups and interventions aimed at reducing smoking by pregnant women and hospital inpatients are likely to be effective. Broader population interventions such as anti-tobacco advertising, price rises for tobacco products and prevention of sales to minors are also likely to be effective in reducing the harm resulting from tobacco use.     

Smoking cessation in indigenous populations of Australia, New Zealand, Canada, and the United States: elements of effective interventions

Indigenous people throughout the world suffer a higher burden of disease than their non-indigenous counterparts contributing to disproportionate rates of disability. A significant proportion of this disability can be attributed to the adverse effects of smoking. In this paper, we aimed to identify and discuss the key elements of individual-level smoking cessation interventions in indigenous people worldwide. An integrative review of published peer-reviewed literature was conducted. Literature on smoking cessation interventions in indigenous people was identified via search of electronic databases. Documents were selected for review if they were published in a peer-reviewed journal, written in English, published from 1990-2010, and documented an individual-level intervention to assist indigenous people to quit smoking. Studies that met inclusion criteria were limited to Australia, New Zealand, Canada, and the USA, despite seeking representation from other indigenous populations. Few interventions tailored for indigenous populations were identified and the level of detail included in evaluation reports was variable. Features associated with successful interventions were integrated, flexible, community-based approaches that addressed known barriers and facilitators to quitting smoking. More tailored and targeted approaches to smoking cessation interventions for indigenous populations are required. The complexity of achieving smoking cessation is underscored as is the need to collaboratively develop interventions that are acceptable and appropriate to local populations.     

Differences in primary health care delivery to Australia's Indigenous population: a template for use in economic evaluations

ABSTRACT: BACKGROUND: Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia's Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting. METHODS: The 'Indigenous Health Service Delivery Template' has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS. RESULTS: The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly. CONCLUSIONS: The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.