Tobacco Control Strategies Review

This assignment reviews various tobacco control strategies, examining their effectiveness and impact. It analyzes research findings from studies on interventions like mass media campaigns, pharmacological support, regulation, and education. The review also considers the specific challenges faced in implementing these strategies within Indigenous communities and explores culturally appropriate approaches to tobacco control.

Running head: RESEARCH LITERACY FOR HEALTH PRACTICE
Literature review on smoking cessation and harm minimization among aboriginals
Name of the Student
Name of the University
Author Note

RESEARCH LITERACY FOR HEALTH PRACTICE 1
Executive summary
In the 20th century, smoking was ubiquitous in Australia. 3 out of 4 men and 1 out of 4 women
were regular smokers. Over the past few decades smoking has led to the development of many
health concerns among people. Tobacco consumption is widespread among Australian
aboriginals and the Torres Strait Islanders. The number of aboriginal smokers is almost double
the rate of smokers in the entire Australian population. Several national surveys and research
studies have been carried out to discover effective intervention techniques that prove useful in
harm minimization and smoking cessation. This report aims to conduct a literature review and
critically analyze the studies that describe effective smoking cessation interventions in the target
indigenous population.

RESEARCH LITERACY FOR HEALTH PRACTICE 2
Table of Contents
1. Introduction..............................................................................................................................3
2. Literature review......................................................................................................................3
a. Search protocol.....................................................................................................................3
b. Inclusion criteria...................................................................................................................4
c. Exclusion criteria..................................................................................................................4
d. Review..................................................................................................................................4
3. Critical appraisal.......................................................................................................................7
a. CASP tool for systematic review..........................................................................................7
b. CASP tool for randomized control trial..............................................................................11
4. Recommendation....................................................................................................................12
References......................................................................................................................................14
APPENDIX 1.................................................................................................................................18
Bibliography..............................................................................................................................18
APPENDIX 2.................................................................................................................................20
Record of major findings...........................................................................................................20

RESEARCH LITERACY FOR HEALTH PRACTICE 3
1. Introduction
Australian indigenous people and aboriginals suffer from shorter life expectancies and higher
burden of ill health conditions when compared to other nations. They have been suffering from
worsened and poor health status since the 1970-1980s. The difference in the health situation
between indigenous and non-indigenous groups is attributed to historical, socio-political and
distal factors. Just like any other nation, the non- indigenous Australian population enjoys a
better life expectancy. According to several studies, aboriginals who live in remote areas are
vulnerable to a higher risk of smoking and poor healthcare facilities (Abs.gov.au, 2017).
Several studies that evaluate the ways by which aboriginal and indigenous smokers can be
influenced and motivate to quit smoking have been conducted. Some studies have illustrated the
different intervention strategies that should be followed to minimize or reduce the harmful
effects of smoking or tobacco consumption on aboriginal health. This report aims to conduct an
extensive literature review and summarize their findings on the effectiveness of interventions
that can reduce harm related to tobacco consumption among indigenous Australian population.
2. Literature review
a. Search protocol
Evidence based literature search to analyze the outcomes and effectiveness of several
intervention services that have been implemented on indigenous Australian population for
cessation of smoking habits and tobacco harm minimization was conducted. The main interest of
this literature review lies in recognizing qualitative and quantitative research studies that gave an
insight into the health outcomes and experiences of aboriginals. A multilevel iterative technique
was designed for the literature search. 3 databases were used: MEDLINE (biomedical literature),

RESEARCH LITERACY FOR HEALTH PRACTICE 4
CINAHL (allied health and nursing literature) and Cochrane library (randomized controlled trials
and systematic review) (Bergamaschi et al. 2016). The abstracts of the retrieved articles were
checked for relevance regarding intervention strategies. The search terms were “smoking
prevalence in aboriginals”, “indigenous smoking harm reduction”, “smoking cessation among
aboriginals”, “aboriginal tobacco control”. The inclusion and exclusion criteria were drawn.
b. Inclusion criteria
 Any intervention that illustrated reduction of smoking or use of commercial tobacco was
selected. The selected interventions were classified to key priority areas based on the
working principles of NATSIHP. Studies were included in the review if they involved
nonmedical therapeutic procedures.
 Peer reviewed journals published in English were used for the systematic review.
 Study literature not more than 5 years old were included in the review.
 The user group was indigenous adults who had smoking habits. The review focused on
vulnerable, special and disadvantaged population group.
c. Exclusion criteria
 Non-English journals and those published prior to 2012 were not considered.
 Interventions that illustrated reduction of ceremonial tobacco use were excluded.
d. Review
Evidence from several data that focused on implementing smoke free policies suggested that
exposure to second hand smoke and prevalence of smoking among young and adolescent
significantly reduced on application of these policies. A study was conducted in the Cultural and
Indigenous Research Centre that proved that stringent legislations related to smoking in public

RESEARCH LITERACY FOR HEALTH PRACTICE 5
spaces has substantially reduced smoking environment over the past decade (Ell, Abel and Pedic
2013). It was suggested by Thomas, McLellan and Perera (2013) that effective media campaigns,
smoking restriction in schools and promoting ill effects of smoking on the health of young
people were effective in reducing the sales of tobacco among minors. When the retail outlets in
the community adhere to the legislative regulations imposed by the government, the sales of
tobacco could be effectively monitored. Another study showed that 3 business organizations out
of 21, operating form the remote areas of Queensland northern communities practiced smoke
free policies. The remaining 18 practiced informal smoking policies and all of these
organizations had smoke free zones. However, these legislations often made the smokers feel
persecuted. They also created a rift between the smokers and non-smokers and created a feeling
of solidarity among them. The workforce should be consulted before implementation of any such
smoke free policies to avoid untoward situations. This acted as a successful, intervention strategy
(Campbell et al. 2014).
An increase in the taxes imposed on tobacco successfully reduced the rate of tobacco
purchase and motivated several people to quit smoking (Chaloupka, Yurekli and Fong 2012).
Randomized control trials, pre and post studies were undertaken to monitor the effect of tobacco
prevention and smoking cessation in indigenous people (Carson et al. 2014). It was found that
smoking levels got considerably reduced in 12 out of 15 controlled trials on follow up. However,
the results of cessation on the younger population were not evident. The study provided evidence
for the combination of behavioral, psychological and biochemical factors to cater to the needs of
indigenous population. Interventions that encompassed a greater number of components
increased the likelihood of reducing smoking levels. Certain indigenous communities from
Australia also proved that increase in the tobacco prices affected smoking rates. 7 months after

RESEARCH LITERACY FOR HEALTH PRACTICE 6
there was an increase in tobacco price, the consumption rates among aboriginals were found to
reduce by as much as 2.2% on an average (Thomas et al. 2012). However, the results were not
consistent across all the stores that were analyzed for the study.
Mass media campaigns and social marketing strategies have an important role to play in
smoking cessation and act as good intervention policies. The campaigns have proved effective in
preventing smoking when they were combined with tobacco control measures (Durkin, Brennan
and Wakefield 2012). These campaigns help in molding and altering the behavior and attitude of
smokers towards tobacco consumption and promote the benefits of abstinence from smoking.
They help in preventing smoking relapse among aboriginals by reminding them the reason
behind stopping smoking (Wakefield et al. 2012). Television has been proved to the most
efficient mode of media strategy that has a wider reach among people belonging to all strata of
population and positively influences adult smokers. Moreover, personal testimonials are also
essential in positively influencing people to quit smoking (Farrelly et al. 2012).
A study that reviewed the effect of smoking among indigenous population by using several
randomized control trials failed to show any significant effects of smoking cessation on both
aboriginal or non-aboriginal Australian population. Higher rates of smoking cessation were
reported among people who were subjected to intervention methods. Cultural approach and
knowledge based awareness drives helped to increase quitting rates (Gould et al. 2012). A
national survey, ‘Talking About the Smokes’, displayed the voice of 3000 indigenous smokers
and non-smokers (Thomas 2014). The survey suggested that future activities, which target
smoking cessation among aboriginals, should utilize the standards of society acceptance for
tobacco consumptions. An intensive program designed for aboriginal population showed
significant reduction rates in smoking quit rates by double amount (Marley et al. 2014).

RESEARCH LITERACY FOR HEALTH PRACTICE 7
A school based disease education program was also conducted that influenced healthy
lifestyle choices among indigenous people and encouraged positive role model influences on the
students. This study was conducted across 20 schools and utilized video campaigns and social
marketing strategies. It proved to have a positive impact on the attitude, knowledge and self
efficacy of the aboriginal students and reduced the impact of smoking among them (Malseed et
al. 2014). The quit rates increased to a significant amount of 12% on application of intensive
counseling therapies. However, disparity between the number of participants adhering to usual
care routines (95) and those using the intervention (49) made the study statistically
underpowered. 11 different approaches that were based on increasing rates of physical activity
among young aboriginals were identified in one study. Out of these approaches, implementation
that targeted the community showed significant and relevant positive effects in smoking
cessation on a follow up after 12 months (Baker and Costello 2014).
3. Critical appraisal
A critical appraisal was undertaken to determine the effectiveness and evidence quality of
each intervention strategy. These CASP tools will help to formulate and design future
recommendations and sustainability of the proposed intervention techniques (Munn et al. 2014).
a. CASP tool for systematic review
Chamberlain et al. 2017 Roche and Ober 1997
Did the review address a clearly
focused question?
Yes (investigated evidence for
tobacco consumption reduction
among indigenous people)
Yes (examined the potential of
harm minimization to address
smoking among aboriginals and
Torres Strait islanders)
Did the authors look for the right Yes (MEDLINE, EMBASE and Can’t tell (No information on the

RESEARCH LITERACY FOR HEALTH PRACTICE 8
type of papers? indigenous health databases were
searched)
search strategy or use of any
database is available)
Were all relevant studies
included?
Yes (21 studies that focused on
effective interventions for
smoking reduction among
aboriginals were included)
Yes (most of the studies that
were assessed focused on
smoking among aboriginal health
workers, tobacco use in
Australia, household and national
surveys and mortality among
indigenous people. However,
some articles on heart diseases,
territory health outcome,
psychoactive harm reduction and
drug addiction were also
considered)
Did the author do enough to
access the quality of included
studies?
Yes (the studies not only
included indigenous participants
from Australia but also focused
on other vulnerable and
disadvantaged population)
Yes (they analyzed several
surveys to identify the essential
elements related to tobacco
reduction and devised approaches
for harm minimization)
If the results have been
combined, was it reasonable to
do so?
Yes, the results were combined
since, thorough analysis of data
from all the included studies
provided access to a variety of
evidence based smoking
cessation practices and suggested
the role of mass media
Yes, most of the studies focused
on decreasing mortality and
morbidity, increasing cessation,
reducing healthcare expenditure
and second hand exposure to
smoke.

RESEARCH LITERACY FOR HEALTH PRACTICE 9
campaigns in harm minimization.
What are the overall results? 4studies reported that a surge in
tobacco taxes and price reduces
their affordability and prompts
quitting of smoking. 3 studies
identified the effectiveness of
implementation of legislative
interventions and pack warnings
in reducing tobacco sales among
minors. Majority of the studies
illustrated that mass media
campaigns, social marketing,
community based strategies
subsequently change the behavior
and perception among tobacco
consumers and promote tobacco
cessation when they are applied
in conjunction with other control
activities. Pharmacological
interventions like use of
bupropion and nicotine
replacement therapies also work
as efficient interventions. The
studies also suggested the
presence of smoke free
environment to reduce second
The study showed that major
harm reduction strategies should
include increasing accessibility to
treatment, decreasing drug
intake, safer delivery routes,
early detection monitoring,
protecting non-smokers by
restricting smoking zones and
destigmatising use by showing
empathy towards aboriginals who
failed to quit smoking.

RESEARCH LITERACY FOR HEALTH PRACTICE 10
hand smoke exposure among
people.
How precise are the results? The review was examined for
similarities with the principles of
NATSIHP. The major priorities
were well identified in most of
the primary studies. However,
some of the secondary studies
failed to provide evidence for
fine aspects of the probable
interventions.
The indigenous community
practiced fewer harm reduction
or cessation approaches than the
wider communities. The study
evaluated the National Drug
Strategy Survey, which showed
that 32 aboriginals had reduced
smoking in 1994, compared to 41
people belonging to the general
population in 1993.
Can the results be applied to
local population?
Yes Yes
Were all important outcomes
considered?
Yes (Effect of elimination of
smoking promotion or
advertising were not identified in
any indigenous population
specific study)
No (effect of media campaigns,
taxation rates and smoking
legislations were not measured)
Are the benefits worth the harm
and costs?
Yes (There were no harms
associated)
Yes (harm reduction concept
needs to be destigmatised among
aboriginals)
b. CASP tool for randomized control trial
Malseed et al. 2014 Marley et al. 2014 Carson et al 2014
Did the trial address a Yes (investigated the Yes (tested efficacy of Yes (evaluated the

RESEARCH LITERACY FOR HEALTH PRACTICE 11
clearly focused issue? effectiveness of health
programs in schools for
aboriginals to combat
chronic health
conditions)
multidimensional
smoking cessation
program on aboriginals)
effectiveness and safety
of VT and quitline on
smokers)
Was the assignment of
patients to treatment
randomized?
No Yes Yes
Were all patients
accounted for at
conclusion?
Yes Yes (study endpoints
were considered at 6
and 12 months after
enrolment)
Yes (12 weeks of
treatment was followed
for all participants)
Were patients, health
workers and study
personnel blind to
treatment?
No The staff were blinded
to the study
Yes
Were the groups similar
at start of trial?
Yes (11-18 years of
students were selected)
Yes (aboriginal and
Torres Strait islanders,
aged more than16 years
were selected)
Yes (all patients were
adults with smoking
related diseases)
Were the groups treated
equally?
Yes (Deadly choice
program was applied to
all)
Yes (all participants
received routine care
related to smoking
cessation
Yes (subjects received
varenicline tartrate and
quitline counseling
together)
How large was the Significant changes Smoking cessation VT was tolerated among

RESEARCH LITERACY FOR HEALTH PRACTICE 12
treatment effect? observed in
intervention group
regarding knowledge
on smoking
rate was double for
intervention group
subjects with acute
smoking illness; self
reported adverse event
was nausea
How precise was the
estimate of treatment
effect?
(P= 0.006) (P= 0.131) (16.3% nausea in the
VT+C group and 1.5%
in the counseling group)
Can the results be
applied in this context?
Yes Yes Yes
Were all clinically
important outcomes
considered?
Yes (physical activity,
leadership education
and health checkup
increases self efficacy
among minors and can
promote smoke
quitting).
Yes (Self reported
smoking cessation rates
were measured at final
follow up)
Yes (effect of
VT+quitline counseling
and of quitline
counseling alone were
measured)
4. Recommendation
Tobacco use has a substantially greater prevalence among Aboriginal and Torres Strait
Islanders when compared to the general Australian population. 42% of the indigenous population
is daily smokers and the smoking rates among them are considerably high (Upton et al. 2014).
However, national surveys suggest that a progressive decline in daily smoking limits have been
observed since the last decade. Several socio-economic factors, psychological stress,
homelessness and exposure to criminal system act as major contributors to high smoking

RESEARCH LITERACY FOR HEALTH PRACTICE 13
prevalence among aboriginals. Several randomized control trials and systemic reviews provide
evidence for the effectiveness of intervention methods on smoking cessation activities. From the
above discussed literature review it can be concluded that smoking cessation interventions
include motivational counseling, peer support programs, pharmacotherapy, increased
educational awareness in ill effects of tobacco consumption, social and mass media campaigns,
tobacco litigation and proper enactment of the legislations at all places, creating smoke free
environments and increasing tax rates on tobacco products.
These intervention programs must be funded because they will help to curb down
healthcare costs significantly (they reduced costs associated with hospitalizations by $ 134
billion in California), will increase productivity at workplace and lead to less occurrence of
disabilities (Lightwood and Glantz 2013). Moreover, if these interventions are funded then they
will reduce medical expenditures and incidence of smoking related chronic diseases. Previously
conducted cessation programs have proved beneficial in reducing the number of adult smokers
and have shown a drastic fall in cigarette sales (Rabius et al. 2014). Therefore, it can be
concluded that if the government agencies and health based organizations increase their funding
on research and development of smoking cessation programs, the aboriginals would be highly
affected and a healthy community will prevail.

RESEARCH LITERACY FOR HEALTH PRACTICE 14
References
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Baker, P. and Costello, J., 2014. Evidence Synthesis on Effective Physical Activity and
Nutritional Health Promotion Programs.
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Campbell, S., Bohanna, I., McKeown-Young, D., Esterman, A., Cadet-James, Y. and
McDermott, R., 2014. Evaluation of a community-based tobacco control intervention in five
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Campbell, S., Bohanna, I., McKeown-Young, D., Esterman, A., Cadet-James, Y. and
McDermott, R., 2014. Evaluation of a community-based tobacco control intervention in five
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RESEARCH LITERACY FOR HEALTH PRACTICE 15
versus counseling alone for smoking cessation: a randomized controlled trial for inpatients
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Chaloupka, F.J., Yurekli, A. and Fong, G.T., 2012. Tobacco taxes as a tobacco control
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program for urban Indigenous young people in Australia. Health, 6(07), p.587.

RESEARCH LITERACY FOR HEALTH PRACTICE 16
Marley, J.V., Atkinson, D., Kitaura, T., Nelson, C., Gray, D., Metcalf, S. and Maguire, G.P.,
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Indigenous Smoking and Healthy Lifestyle Programme Review: A Rapid Review of the
Literature.

RESEARCH LITERACY FOR HEALTH PRACTICE 17
Wakefield, M.A., Bowe, S.J., Durkin, S.J., Yong, H.H., Spittal, M.J., Simpson, J.A. and Borland,
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RESEARCH LITERACY FOR HEALTH PRACTICE 18
APPENDIX 1
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S37.

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