Smoking Cessation Strategies for Indigenous Australians

This assignment analyzes smoking cessation programs and their impact on Aboriginal and Torres Strait Islander (ATSI) Australians. It reviews several studies, highlighting the unique barriers faced by indigenous populations and comparing the success rates of different intervention approaches. The review emphasizes the need for culturally tailored interventions and support systems to effectively address smoking among ATSI communities.

Research Literacy for Health Practice
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Introduction:
People of Aboriginal and Torres Strait Islander population are more susceptible to smoking
addiction development as compared to the non-indigenous communities. It is evident that
smoking has multiple negative effects on the health of these people. Nature of smoking can
be adaptive and addictive. Social, economic and structural factors are responsible for the
more prevalence of smoking in this population. It has been observed that more prevalence of
smoking in this population is mainly due to the insufficient training for smoking cessation.
Aboriginal health workers who smoke cannot provide training because of their cognitive
decline. Due to smoking, there is higher incidence of stroke, heart disease, diabetes and
circulatory disease in aboriginal population (Vos et al., 2009). Less attention to the smoking
cessation programmes may be due to less visible impacts of smoking as compared to the
alcohol consumption. Negative impacts of smoking can be evident only after diagnosis of
certain disease. Hence, there is less awareness of potential detrimental effects of smoking
among aboriginal origin people. In the surveys, it is evident that less than 5 % aboriginal
people knows that smoking can negatively affect their health. As a result, very less efforts
were made for reducing smoking in this population. For aboriginal people, cultural
dominance is also one of the important factor responsible for the smoking prevalence. Supply
of tobacco along with regular ratio, was one the major factor responsible for the prevention of
smoking in the aboriginal population. Consumption of Tabaco was carried forward form the
complex historical antecedents to current-day tobacco users in this population (Robinson et
al., 2010).
Poverty in aboriginal people is also considered as one of the factor for augmented smoking in
aboriginal people. These people try to present their life as luxury life and social acceptance
through smoking. Because of these complex causes and sustained increase in the smoking, it
would be challenging to control smoking in this population. Until recently, most the
prevention methods of smoking are traditional methods. However, in recent past newer
methods like harm reduction are implemented. Harm reduction strategy involves efforts to
reduce adverse effects and social and economic consequences of smoking without reducing
consumption of smoking. In this harm reduction approach, there would be acceptance of
tobacco use of person and maintenance of dignity of the person. Harm reduction in smoking
can be achieved by reducing recruitment, increasing cessation, reducing risks of active and
passive smoking. Integration of harm reduction approaches and cessation approaches proved
beneficial in individual and public status of aboriginal people. However, most of the
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aboriginal people feel smoking cessation is a difficult task for them because these people
can’t offered to spend time and energy in smoking cessation intervention (MRoche & Ober,
1997).
Literature search:
Literature search was carried out by using different databases like Embase, Ovid MEDLINE,
PsychINFO and CINAHL. Literature search is divided into three categories. These categories
include indigenous people, tobacco or smoking use and intervention. Ingenious people search
strategy include aboriginal people, native Australians and Torres Strait Islander. Tobacco
search strategy include tobacco, smoke, smoking, cigar, tobacco use and cigarettes.
Intervention search strategy include smoking intervention, smoking reduction, tobacco
control, smoking cessation, tobacco reduction, smoking restriction, tobacco reduction
strategy, quit smoking and tobacco control strategy. These search items were searched
individually and in combination based on the database. Different criteria were used for the
selection of articles. First, article should be published. Second, intervention should be carried
out on Aboriginal Australian people. Articles were selected comprising of research designs
like interventions, case control, cohort, cross-sectional, experimental, and intervention
designs. Articles between 1996 to 2016, were selected. All these databases yielded 1714
articles and after removal of duplicates 1345 articles were obtained. In the final step, 31
eligible articles were selected relevant to the essay.
Critical appraisal:
Critical appraisal of the research article should be carried out under different aspects like title
and abstract, structuring of the study, sample selection, data collection, data analysis, findings
and conclusion. Aims, objectives and hypothesis should be clearly mentioned in the research
article. Data collection method should be clearly explained and expertise of the data
collection person should incorporated. Ethical issues in the data collection should clearly
mentioned. Reliability and validity of the data collection instruments and methods should be
adequately described. In data analysis name of the statistical methods like primarily
descriptive, correlational or inferential should be mentioned. Whether results are clinically or
statistically significant should be clearly mentioned. Whether is study is blinded should be
clearly mentioned to eliminate question of bias. Outcome of each statistical analysis should
be identified and meaning of each outcome should be explained. Results should be clearly
and completely stated and enough information should be provided to judge the results.
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Researcher should provide summary of the obtained results and made suggestions for the
future studies. Limitations and implications of the study should be clearly mentioned. Enough
information should be provided in the study to replicate the study. Discussion should be
provided in the article comprising of participants values, clinical expertise and available
evidence (Kmet et al., 2004; Smylie et al., 2016).
Different types of research are available for the smoking cessation. These include randomised
controlled trials, controlled clinical trials, pre-post studies and government reports.
Methodological problems in the form of study design were observed in few of the studies. In
few of the pre-post studies and government reports, there is no mention of either randomised
or non-randomised controlled study. Data for the comparator population is not mentioned in
none of the government reports (Australian Bureau of Statistics, 2013; 2014b). Data related
to subject recruitment is clear in most of the studies. Most of the studies are not meeting the
criteria for the mentioned number of subject population. Less number of subjects are
incorporated in the studies as compared to the mentioned number. Available studies are with
less population, hence generalisability of the data is difficult. There is more attrition rate in
the number of subjects in the follow-up studies. Moreover, reason behind the attrition rate
was not mentioned. As a result, generalisability and comprehensiveness of the follow-up
studies is questionable. Data related to characteristic of population those who participated in
the follow-up and those who didn’t participated in the follow-up is missing form these studies
(Marley et al., 2014; Passey et al., 2009).
Different factor like socio-economic status and cultural aspects can affect the outcome in the
smoking cessation studies. However, in few studies these aspects were not categorised in the
analysis of results. Categorisation of results based on these aspects would have given more
clarity of the smoking cessation interventions. There could be different outcomes in the
smoking cessation studies like continuous smoking self-denial, point prevalence and
complete acceptance of the intervention. However, in few of the studies, results were not
categorised according these categories (Cosh et al., 2015; Gould et al., 2013). Data collected
in these studies by different stakeholders like Indigenous health workers, research assistants
and doctors. However, expertise and experience of these stakeholders in the smoking
cessation is not mentioned in these articles. Research and survey data collected by the experts
should be considered as the valid data. Hence, collected data in few these studies is
questionable. In these studies, data is collected by face-to-face interaction, self-reports and
online assessment. Data collection methods like self-reports and online assessment are prone
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to bias. Self-reports can be collected in the presence of health or social worker to improve
validity of the data (Tooth et al., 2005).
There is flaw in the statistical analysis in few of the studies. There is huge difference between
statistical significance and clinical significance. However, statistical significance is the most
important requirement for the validity of the data. Statistical significance is not possible in
the studies without comparator and in studies with insufficient power to detect the effect. In
most of the studies, mentioned conclusion is not comprehensive and it reflects only some part
of the study. Few of the studies specifically mentioned category of subject population. This
information would be helpful in the assessment of smoking intervention population. Quality
of research can be assessed based on the clarity of the category of subject population. 17
studies were specifically carried out on the adults and 14 studies were carried out on both
adults and young. Studies should also mention specific aims and objectives of the research. It
would be helpful in the assessing understanding of the researcher about the research area.
Approximately 12 studies studied both prevention and cessation intervention programmes, 17
studies studied just cessation and only two studies studied tobacco prevention. Locality or
geographic location of the subject population is important aspect in studies like smoking
cessation because smoking cessation can be affected by different factors like cultural and
socio-economic factors. These studies were carried out in different regions like Northern
Territory, Queensland, New South Wales, Australian Capital Territory, Victoria, Tasmania,
South Australia and Western Australia. However, none of the studies were carried out based
on the comparison among different regions. Comparative studies among different regions
would have given more generalisation of the research design and methods used in these
studies. Interventions used in these methods were in the form of media education,
counselling, incorporation of social or healthcare workers and pharmacotherapy. Very less
studies were performed with combination of these interventions (Gould et al., 2013;
Nicholson et al., 2015).
Study conducted by Mckennitt and Currie, 2012; didn’t allowed direct comparison between
intervention group and control due to small sample size. Another study conducted by Glover
et al. 2009, also produced confounding results due to small sample size. In this study, results
were obtained in the favour of control group. Campbell et al. 2014 conducted a controlled
clinical trial in 702 Aboriginal and TSI Australian people above 15 years of age. In this study,
motivational counselling was provided by the trained healthcare professionals. This study
conducted in both rural and urban areas with incorporation of sufficient number participants.
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Hence, in this study statistically results were obtained and these results can be generalised to
overall population. If recruited participants would have been equally distributed among rural
and urban populations, more evident results in the form of effect of different classes of people
on smoking cessation, would have been obtained. Marley et al. 2014, conducted randomised
clinical trial in 168 Aboriginal Australian people above age of 16. In this study, interventions
like motivational interview and pharmacotherapy were used together. However, main
drawback of this study was its less number of participants. Hence, in this study clinical
difference was obtained among control group and intervention group. However, there was no
statistical difference between these two groups. Hearn et al. 2011; conducted pre post study in
Aboriginal Australian people. In this study, smoking cessation training was provided. Even
though study population was less in this study, statistically significant difference between
control group and intervention group was observed. These results might be obtained because
intervention was carried out by expert professionals in in Aboriginal health and education.
Conclusion:
It has been observed that reductions in the smoking are evident in the Aboriginal people of
Australia, however these are coming at very low speed. It is evident form the literature that
studies comprising of integrated interventions targeted towards biochemical, habit forming,
cultural, stress related and psychological aspects, proved beneficial in the smoking cessation.
These interventions proved more beneficial in the people those are already motivated for
smoking cessation. Hence, these interventions should be considered as support mechanism
rather than tool. Research design and clinical practice efforts should be directed towards
making transition of these interventions from support mechanisms to tool for smoking
cessation. In studies, it has been established that pharmacotherapy is successfully
implemented in smoking cessation. Studies comprising of pharmacotherapy, produced
statistically and clinically significant results in the smoking cessation. However,
pharmacotherapy was underused in Aboriginal Australian people. Other intervention
techniques like training to healthcare professionals for smoking cessation, motivational
interview techniques, behavioural support and interventions considering cultural aspects,
traditions and languages proved beneficial in smoking cessation. From the literature, it is
evident that identifying unsuccessful intervention is difficult task. Hence, more efforts should
be made to identify unsuccessful intervention. Effective evaluation procedures should be
implemented for smoking cessation programmes. Integrated efforts of health workers, social
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workers and government agencies would be helpful in implementing effective smoking
cessation programme in Aboriginal Australian population.
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References:
Australian Bureau of Statistics. (2013). Profiles of Health, Australia, 2011-13 Canberra:
Australian Bureau of Statistics, viewed 18 September 2017
<www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4338.0~201113~Main
%20Features~Tobacco%20smoking~10008>. Australian Bureau of Statistics 2014a.
4727.0.55.001.
Australian Bureau of Statistics. (2014b). Australian Aboriginal and Torres Strait Islander
Health Survey: Updated Results, 2012–13, Canberra: Australian Bureau of Statistics, viewed
18 September 2017, <www.abs.gov.au/AUSSTATS/abs@.nsf/mf/4727.0.55.006>.
Cosh, S., Hawkins, K., Skaczkowski, G., Copley, D., & Bowden, J. (2015). Tobacco use
among urban Aboriginal Australian young people: a qualitative study of reasons for smoking,
barriers to cessation and motivators for smoking cessation, Australian Journal of Primary
Health. 21(3), pp. 334-41.
DiGiacomo, M., Davidson, P.M., Davison, J., Moore, L., & Abbott, P. (2007). Stressful life
events, resources, and access: key considerations in quitting smoking at an Aboriginal
Medical Service. Australian and New Zealand Journal of Public Health. 31(2), pp. 174-176.
Eades, S.J., Sanson-Fisher, R.W., Wenitong, M., Panaretto, K., D'Este, C., Gilligan, C., &
Stewart, J. (2012). An intensive smoking intervention for pregnant Aboriginal and Torres
Strait Islander women: a randomised controlled trial. Medical Journal of Australia. 197(1),
pp. 42-46.
Gould, G.S., McGechan, A., and van der Zwan, R. (2009). Give up the smokes: a smoking
cessation program for Indigenous Australians, 10th National Rural Health Conference,
viewed 18 September 2017,
www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/papers/docs/
Gould_Gillian_D9.pdf.
Gould, G.S., Munn, J., Watters, T., McEwen, A., & Clough, A.R. (2012). Knowledge and
views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres
Strait Islanders: A systematic review and meta-ethnography. Nicotine & Tobacco Research.
15(5), pp. 863-74.
Gould, G.S., Munn, J., Avuri, S., Hoff, S., Cadet-James, Y., McEwen, A., & Clough, A.R.
(2013). Nobody smokes in the house if there's a new baby in it”: Aboriginal perspectives on
tobacco smoking in pregnancy and in the household in regional NSW Australia, Women and
Birth. A journal of the Australian College of Midwives. 26(4), pp. 246-253.
Hearn, S., Nancarrow, H., Rose, M., Massi, L., Wise, M., Conigrave, K., Barnes, I., &
Bauman, A. (2011). Evaluating NSW SmokeCheck: a culturally specific smoking cessation
training program for health professionals working in Aboriginal health. Health Promotion
Journal of Australia. 22(3), pp. 189-198.
Ivers, R.G., Farrington, M., Burns, C.B., Bailie, R.S., D'Abbs, P.H., Richmond, R.L., &
Tipiloura, E. (2003). A study of the use of free nicotine patches by Indigenous people.
Australian and New Zealand Journal of Public Health. 27(5), pp. 486-490.
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Kmet, L.M., Lee, R.C., & Cook, L.S. (2004). Standard quality assessment criteria for
evaluating primary research papers from a variety of fields. Alberta Heritage Foundation for
Medical Research. 2004. http://www.biomedcentral.com/ content/supplementary/1471-2393-
14-52-s2.pdf. Viewed on 19 September 2017.
Marley, J., Atkinson, D., Kitaura, T., Nelson, C., Gray, D., Metcalf, S., & Maguire, G.P.
(2014). The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an
intensive smoking cessation intervention in a remote Aboriginal Australian health care
setting. BMC Public Health. 14, pp. 32-41.
McKennitt, D.W., & Currie, C.L. (2012). Does a culturally sensitive smoking prevention
program reduce smoking intentions among Aboriginal children? A pilot study. American
Indian and Alaska Native Mental Health Research. 19(2), pp. 55-63.
MRoche, A., & Ober, C. (1997). Rethinking Smoking Among Aboriginal Australians: The
Harm Minimisation.Abstinence Conundrum. Health Promotion Journal of Australia. 7(2),
128-133.
Nicholson, A.K., Borland, R., Couzos, S., Stevens, M., & Thomas, D.P. (2015). Smoking-
related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait
Islander people. Medical Journal Australia. 202(10), pp. S45-50.
Passey, M., Gale, J., Holt, B., Leatherday, C., Roberts, C., Kay, D., Rogers, L., & Paden, V.
(2009). Stop smoking in its tracks: understanding smoking by rural Aboriginal women,
Paper presented at the 10th National Rural Health Conference, Cairns, Australia, viewed 18
September 2017, <www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/papers/
docs/Passey_Megan_D9.pdf>.
Robinson, M., McLean, N.J., Oddy, W.H., et al. (2010). Smoking cessation in pregnancy and
the risk of child behavioural problems: a longitudinal prospective cohort study. Journal of
Epidemiology and Community Health. 64, pp. 622–9.
Smylie, J., Kirst, M., McShane, K., Firestone, M., Wolfe, S., & O’Campo, P. (2016).
Understanding the Role of Indigenous Community Participation in Indigenous Prenatal and
Infant Toddler Health Promotion Programs in Canada: A Realist Review. Social Science &
Medicine. 150, pp. 128-143.
Tooth, L., Ware, R., Bain, C., Purdie, D.M., & Dobson, A. (2005). Quality of Reporting of
Observational Longitudinal Research. American Journal of Epidemiology. 161(3), 280-288.
Vos, T., Barker, B., Begg. S., et al. (2009). Burden of disease and injury in Aboriginal and
Torres Strait Islander Peoples: the Indigenous health gap. International Journal of
Epidemiology. 38, pp. 470–7.
Appendix: Literature search and key findings
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Study reference and
design
Intervention
duration, Sample (n)
and age in years
Intervention
description
Findings
Cosh, Hawkins,
Skaczkowski, Copley,
& Bowden 2014 Pre
post study
Duration - 1 year;
Aboriginal and TSI
Australians Australia;
Number of participants
281, Age – 15 years
and above
Telephone counselling
was performed on one-
to-one basis. South
Australian Quitline
telephone smoking
cessation service was
recruited for
counselling.
More number of Non-
indigenous people
successfully quit
smoking as compared
to the indigenous
people.
Indigenous people are
less likely to use
cessation medications
like varenicline or
bupropion as
compared to the Non-
indigenous people.
Eades et al. 2012
Randomised Clinical
Trials
Duration – 9 months;
Aboriginal and TSI
Australians Australia,
Number of participants
– 263;
Age of participants –
16 years and above
Advise, support and
instructions were
given to quit smoking
to the pregnant by
general practitioner
and other health
workers. Evidence
based communication
skills were
implemented to
women’s family
members to quit
smoking. Control
groups receive normal
treatment and
guidance by healthcare
Post 36 weeks, no
difference was
observed between
intervention group and
control group.
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professionals. If two
attempts of
counselling failed in
these women, nicotine
replacement therapy
(NRT) was given.
Gould et al. 2009 Pre
post study
Duration – 2 months;
Aboriginal Australia;
15 participants with
age above 18 years.
Implemented Give Up
the Smokes (GUTS)
programme by general
practitioner and other
healthcare
professional. This
programme include
three hours session per
week for three weeks.
NRT was provided for
three weeks. Culturally
related smoking
intervention
programmes were
implemented like
motivation to quit
smoking, stress
management,
behavioural change
and pharmacotherapy.
After six months
follow up , it was
observed that 30 %
more indigenous
people quit smoking as
compared to the non-
indigenous people.
Digiacomo, Davidson,
Davison, Moore, &
Abbott 2007
Duration – 10 months;
Aboriginal and TSI
Australians Australia;
Number of participants
– 37;
Age – 18 – 70 years
High intensity
smoking cessation by
Aboriginal health
worker at primary care
centre and suburban
Aboriginal Medical
Service centre.
90 % of the
participants reported
quit smoking, however
there was no
statistically significant
data due to less
number of participants.
Participants reported
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life stress as the major
barrier to quit
smoking. Abstinence
not reported in this
study.
R. G. Ivers et al. 2003
Controlled Clinical
Trial
Duration – 10 weeks;
Aboriginal and TSI
Australians Australia;
111 participants were
recruited with age 18
and above.
In this study,
comparison was done
between combination
including NRT and
smoking cessation
intervention and
smoking cessation
alone. Smoking
cessation include
advice to quit
smoking, guidance on
health impacts of
smoking, targeting quit
date and counselling
on cessation.
Intervention groups
produced more
decrement in the
smoking and tobacco
consumption as
compared to the
control group.
However, statistical
significance was not
observed due to less
number of participants.
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