Health Promotion: Analysis of Harm Minimization for Indigenous Smokers

This report critically examines the application of harm minimization and smoking cessation strategies within Indigenous Australian cohorts, focusing on the work of Ober and Roche (1997). The report reviews various studies, including those on electronic cigarettes, global impacts of smoking, and exercise for withdrawal symptoms, to assess the effectiveness of harm reduction approaches. It highlights the importance of considering the specific health and cultural contexts of Indigenous communities. The analysis reveals the need for multidisciplinary interventions, including public health strategies, clinical interventions, and consideration of the rigor of the studies reviewed. The report also discusses the limitations of the original article, such as the lack of statistical analysis and the absence of a systematic review approach. It emphasizes the need for further research and the application of harm reduction strategies to address the high prevalence of smoking and its associated health risks within this vulnerable population. The report also suggests incorporating confidence intervals in the study design while doing the statistical operations so that the causative factors may be adequately identified.

Running head: HEALTH PROMOTION
Health Promotion
Name of the Student:
Name of the University:
Author Note:

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Assessment Task 2
Harm minimisation and smoking cessation among Indigenous cohorts
In today’s world, smoking is a major public health issue that calls for greater attention
and prudent intervention considering the adverse impacts it might exert upon the health status of
the individuals who resort to such habits. There have been ongoing efforts to combat these bad
habits across vulnerable population who might be most susceptible to face the wrath of the
smoking behaviour. One such interventional approach meant for mitigation of these adverse
impacts includes harm minimisation alongside other modality like that of smoking cessation. The
work by Ober and Roche (1997) has laid focus on potentially utilizing the harm reduction
principles in order to address the issue of smoking among Indigenous Australian population of
Aboriginal and Torres Strait Islanders, more frequently prevalent than non-indigenous
population. Thus, the opinion piece has clearly referred to the studied population thereby striving
to address the clearly focused question in course of its proceedings.
The authors Ober and Roche (1997) in order to address their research questions have
looked for a plethora of papers that attended to similar causes and issues. Most of the papers that
the authors reviewed were opinion pieces whereby the respective authors have highlighted on
issues regarding addictive behaviors like that of alcoholism, smoking and drug abuse. Very few
papers have been chosen that were in line with the topic of harm minimization in case of
smokers exclusively. Moreover, there were no specific study designs for most of the journal
articles that were being referred to in the chosen article.
A small-scale literature review of articles on the chosen topic will be conducted in order
to locate similar articles that are of particular significance in relation with the issue that is being

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considered for appraisal. An appropriate critical appraisal tool such as that of CASP (Critical
Appraisal Skills Program) tool will adopted to consider effectiveness and rigor to aid in
comparison of quality of evidence between studies. Efforts will be directed to identify whether
the findings of these articles validate or refute the recommendations of the provided articles.
Google Scholar database will be utilized in order to gain understanding of the topic with search
terms like that of ‘smoking and Indigenous cohorts’ and ‘harm minimization principles of
smoking in Indigenous cohorts’. Similar and or associated studies will be referred to for
accumulating pertinent data in liaison with the topic so that greater insight may be gained for
generating better understanding.
Study by McRobbie et al. (2012) revealed that smoking an electronic cigarette (EC)
containing nicotine increased the chances of smoking cessation in long-term in contrast to EC
without nicotine. Thus, effectiveness of ECs in long-term smoking cessation has been observed.
Jha and Peto (2014) presented statistical records describing the global impacts associated with
smoking behavior, of quitting and in relation to taxing tobacco. Tobacco-attributed mortality as
seen through national trends in UK, US and Poland has been depicted as well that further
necessitated the utility of harnessing harm minimization strategies to combat the smoking
adversities. Longer the smoking duration, shorter life expectancy was noted in the smoker
individuals. Taylor, Ussher and Faulkner (2007) focused on recommending specific doses of
exercise to manage the cigarette craving and withdrawal symptoms. Behavioral regulation in
mitigation of smoking harm has thus been suggested. In another study by Gorber et al. (2009)
emphasis has been laid on acquiring specific data related to accurate estimation of smoking
status to drive suitable interventional strategies. Further, Fagerström and Bridgman (2014) stated
that smoking related health hazards and mortality rates might be mitigated through adoption of

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harm minimization techniques like that of implementation of licensed medicinal nicotine
products through promotion of public health awareness.
Reviewing the content of the work presented by Ober and Roche (1997) it may be said
that in connection with the time in which it was published, efforts may be witnessed on their
parts to incorporate studies that are most relevant. Many studies that are being referred to in the
chosen article have articulated certain vital aspects related to addictive nature of smoking in
addition to its adaptive and functional role. Discussions have also been made with respect to
motivators and reinforcers that encourage the uptake as well as continuation of smoking among
the Aboriginals. Perspectives of these people with respect to health and their relevance to
smoking has been outlined as well in conjunction with reference to components of harm
reduction strategies have also been described. Traditional practices of harm minimization have
been emphasized throughout the discussion. However, the most recent advancements in relation
to smoking cessation and reduction by utilizing electronic cigarettes have been largely
overlooked as depicted through valid studies (McRobbie et al. 2012, Polosa et al. 2011). The
global effects of smoking as well as quitting or levying of taxes on smoking have also not been
taken into consideration, while other studies have highlighted this aspect for better understanding
the harm minimization issue in smoking (Jha and Peto 2014). No studies that have been
published in languages other than English has been included. Moreover, there is no clear
indication as to which databases were explored for procuring the most suitable articles that
further delineates the reliability of the findings expressed in course of the original article.
Authors Ober and Roche in course of their review did little to assess the quality of the
included studies. It is not evident in the proceedings of the article that rigor of the identified
studies were well evaluated making it difficult to rely on the facts and information stated in

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consequence to these findings. More actions could have been undertaken by the authors to
understand the rigor of the studies referred to, thereby improving the quality of information that
is being provided because of systematic reviewing of the articles. The nature of the study design
that is whether they are retrospective or randomized control trial or cohort study might have
provided a clearer insight onto the topic. A much-generalized approach has been sought in
elucidating the harm reduction strategies for smoking in the Indigenous cohorts. Elements that
are integral to define the harm reduction strategies has been mentioned without elaborating the
implications for such propositions. Poor health outcomes due to smoking and perceptions
surrounding this behavior have been taken into account alongside understanding about the
adaptive nature of smoking. Recent studies concerning the disease burden because of exposure to
second-hand smoke has also been explored through retrospective analysis whereby it has been
emphasized that extension of public health strategies in coalition with clinical interventions
might offer effective resolutions to combat ill effects of passive smoking (Öberg et al. 2011).
Harm reduction is not a one-dimensional approach, instead calls for multidisciplinary
interventions to tackle cigarette cravings, subsequent withdrawal symptoms that has been
confirmed through recent investigations. Management of these crucial issues with respect to
smoking has suggested on using exercise that normally works through stress reduction or
neurobiological mechanisms (Taylor, Ussher and Faulkner 2007). Consideration of rigor of
studies would have accentuated the feasibility of findings as represented in the article.
In the article by Ober and Roche (1997), mention has been made with respect to other
articles that have offered insight into the topic succinctly. Combination of the results of the
review has been done to represent distinctive themes in connection with the topic suitable for
analysis in consecutive fashion. The findings as stated across diverse studies have been presented

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haphazardly instead of doing so in a systematic and well-organized manner that further devalued
the chances of incorporating the findings as valid and reliable ones. Clumsy representation of the
study findings have decreased the clarity of the research topic and decreased the reliability of the
work. On the contrary, it has been represented in other systematic review study that a specific
correlation between two interacting variables suggests the possible relation among the two. A
study was conducted to evaluate the association between self-reported smoking status and
smoking status represented through measures of cotinine in biological fluids. A definite search
strategy was invested in order to retrieve the most relevant studies that met the inclusion criteria.
Examination of the association between the variables was noted through such systematic review
(Gorber et al. 2009). However, no such efforts was noted in case of the given article. The
rationale behind combining the results of various articles hence cannot be justified properly as
the results depicted in those articles were not properly interpreted or analyzed. Correct analysis
of such findings would have generated better outcomes in terms of systematic representation of
the study findings.
The overall results of the review has brought to the forefront certain central themes that
reiterates the need to focus more on the smoking issue among the Aboriginal Australians. The
study represented that until date little attention has been given to the issue of harm reduction
strategies in relation to smoking. Owing to the greater propensity of occurrence of smoking
among the Indigenous Australians in addition to harboring negative health effects, harm
reduction approaches may have positive utilities. This group of Aboriginal Australians may be
benefited through following of the recommendations of harm reduction strategies. The study
outcomes have been depicted very vaguely without any statistical tools employment to discuss
the findings. The method utilized in outlining the pivotal ideas as emerged through thematic

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analysis of the topic has not been accurately demonstrated that further added to deter the
reliability with respect to study findings. The bottom line representation of the results is rather
haphazard and sketchy instead of being concrete and conclusive. No numerical representation of
data was noted that reduced the feasibility and usage of the data retrieved. The expression of
results did not go through any sort of rigorous statistical analysis that decreased the potential of
the study to a large extent. Lack of statistical interpretation caused to lessen the gravity of the
study findings significantly. Relevant findings in literature have argued in favor of proposition of
rational public policy in an effort to cause tobacco harm reduction through appropriate risk
analysis and subsequent recommendations (Sweanor, Alcabes and Drucker 2007).
Analysis of the results in the chosen article authored by Ober and Roche (1997), suggests
that there is a lack of precision in representing the study findings. The article did not utilize any
statistical tool because of which no confidence intervals have been used in the study outcomes.
Therefore, the results depict that type of data being qualitative in nature there lie less scope of
putting it into the radar of statistical evaluation. Hence, lack of precision in the result
interpretation is suggestive of the dearth of performing statistical computations with the available
data as the nature of data is entirely qualitative. On the other hand, it has been depicted through
appropriate studies that cohort study may essentially incorporate confidence intervals in their
study design while doing the statistical operations so that the causative factors may be adequately
identified. Follow up studies with suitable cohort respondents attempted to investigate the
parameters related to quit attempts, motivation to quit, smoking status, weight and weight
concern, nicotine cue, withdrawal symptoms, health-related factors in addition to smoking
cessation aids. Findings suggested that in a model of cessation, motivation plays a crucial role to
foster quit attempt while plays lesser role in cases of relapse (Zhou et al. 2009). Hence, lesser

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precision in terms of the study findings may be largely attributed to the study design and lack of
rigorous statistical application.
Deeper retrospection into study findings reveals that the study outcomes is applicable to
only the Aboriginal Australian community only. The entire study has been undertaken with
respect to contextual analysis of the Indigenous cohorts of Australia. The measures and strategies
that have been suggested for mitigation of problems are only concerned with this vulnerable
population. The findings are not generalizable to other populations thereby restricting its
application to other Indigenous cohort population. Across the globe, initiatives have been
streamlined to remedy the smoking menace through improvisation and implementation of harm
reduction strategies. Studies have highlighted on incorporation of suitable strategies that may be
unanimously accepted and followed in the form of policy to drive optimal benefits in mitigating
smoking related adverse health impacts for the concerned population. In this connection,
smokeless tobacco has been suggested as a harm reduction measure to be incorporated within a
policy framework (Gartner et al. 2007). Further, in another study efforts are evident to regulate
nicotine product by means of prudent application of harm reduction measures to curb the
threatening problems of tobacco smoking (Britton and Edwards 2008). Therefore, considering
the plethora of opportunities that rest with respect to expanding the results into the local
population, cautions must be undertaken to gauge the applicability of similar measures in the
context of other similar population in diverse situational context. The differences in
characterizing the harm reduction measures across the population need to be taken into
consideration while applying the results to other population in different context.
The article by Ober and Roche (1997) has paid considerable attention to address certain
outcome measures. Both the addictive as well as adaptive nature of smoking apart from its

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functional role has been mentioned. Both the motivators and reinforcers responsible for the
uptake and continuation of smoking by Aboriginal people have been considered for discussion.
As opposed to the cessation strategies that are part of the traditional approaches, the utility of the
harm reduction measures as tools of ameliorating smoking have also been part of the discussion
of the chosen article. The outcomes have been discussed under various themes where focus was
essentially laid upon smoking among Aboriginal health workers with reference to prevalence
rates and perceptions about the effects of smoking. The feasibility of the adoption of the harm
reduction strategies are also analyzed through suitable references to various relevant articles that
corroborated with the study outcomes. The appropriateness of the strategies may be understood
in the light of other relevant article that threw light in similar issue. Recent investigations have
also attended to the potential of reducing harm because of tobacco smoking. In order to improve
public health, regulated and safer nicotine alternatives have gained prominence in today’s world
that has the capacity of exerting discernible impacts through use of potential alternatives like that
of electronic cigarettes and others (Fagerström and Bridgman 2014). In the chosen article,
mainly the behavioral aspect related to smoking and harm reduction strategy has been
highlighted in contrast to the traditional abstinence program. Information related to other aspects
such as that concerning the alternatives available to mitigate smoking menace has been
overlooked grossly.
The results of the study findings of the article have focused on resorting to harm
reduction strategies rather than traditional approaches which mostly comprised of conforming to
abstinence programs. It has been further mentioned in the article that abatement of adverse health
outcomes due to smoking may be facilitated through recruitment of suitable strategies that aimed
to mitigate the smoking issue to a considerable extent. For the Aboriginal community in

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Australia, adoption of harm reduction approaches might be an effective way of combating the
adverse outcomes that may be effectively used in the community group context. Application of a
wider flexible array of approaches may further contribute to account for harm reduction in the
concerned community. With the passage of time, novel approaches and initiatives have come up
that direct to lessen the impact of smoking through adoption of suitable harm reduction
strategies. Among the initiatives that are in vogue, electronic cigarettes have garnered more
attention as choicest tobacco harm reduction product (Bergen, Nissen and Phillips 2009). The
analysis of profile users of e-cigarettes alongside its utilization, satisfaction and perceived
efficacy has been undertaken to perceive the issue of smoking on a broader spectrum (Etter and
Bullen 2011). Therefore, judging the relative importance of benefits associated with harm
reduction strategies in contrast to the cost incurred and harm it may be said that it may be useful
if the harm reduction strategies are put in force appropriately.
Based on the knowledge and information gained by critically appraising the article and
undertaking short literature review, it may be said that incorporation of the most relevant
strategies might be beneficial in tackling the smoking menace among the Indigenous cohorts. In
order to account for harm minimization in case of tobacco smoking, prudent and pragmatic
approaches must be directed to drive positive outcomes. Traditional approaches for harm
minimization must be replaced by novel and effective methods that will result in generation of
more optimal results. As per evidences provided through recent investigations, electronic
cigarettes have garnered much attention in curbing harm due to smoking of tobacco that may be
considered for further exploration as a suitable alternative. Hence, funding should be given to
interventions that aim to streamline initiatives for reducing harms linked with smoking cigarettes
that contain tobacco.

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References
Bergen, P., Nissen, C. and Phillips, C.V., 2009. Electronic cigarettes (e-cigarettes) as potential
tobacco harm reduction products: Results of an online survey of e-cigarette users Karyn Heavner
James Dunworth.
Britton, J. and Edwards, R., 2008. Tobacco smoking, harm reduction, and nicotine product
regulation. The Lancet, 371(9610), p.441.
Etter, J.F. and Bullen, C., 2011. Electronic cigarette: users profile, utilization, satisfaction and
perceived efficacy. Addiction, 106(11), pp.2017-2028.
Fagerström, K.O. and Bridgman, K., 2014. Tobacco harm reduction: the need for new products
that can compete with cigarettes. Addictive behaviors, 39(3), pp.507-511.
Gartner, C.E., Hall, W.D., Chapman, S. and Freeman, B., 2007. Should the health community
promote smokeless tobacco (snus) as a harm reduction measure?. PLoS Medicine, 4(7), p.e185.
Gorber, S.C., Schofield-Hurwitz, S., Hardt, J., Levasseur, G. and Tremblay, M., 2009. The
accuracy of self-reported smoking: a systematic review of the relationship between self-reported
and cotinine-assessed smoking status. Nicotine & tobacco research, 11(1), pp.12-24.
Jha, P. and Peto, R., 2014. Global effects of smoking, of quitting, and of taxing tobacco. New
England Journal of Medicine, 370(1), pp.60-68.
McRobbie, H., Bullen, C., Hartmann-Boyce, J. and Hajek, P., 2012. Electronic cigarettes for
smoking cessation and reduction. Cochrane Database Syst. Rev, 12.

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Ober, C. and Roche, A.M., 1997. Rethinking smoking among Aboriginal Australians: the harm
minimisation-abstinence conundrum. Health Promotion Journal of Australia: Official Journal of
Australian Association of Health Promotion Professionals, 7(2), p.128.
Öberg, M., Jaakkola, M.S., Woodward, A., Peruga, A. and Prüss-Ustün, A., 2011. Worldwide
burden of disease from exposure to second-hand smoke: a retrospective analysis of data from
192 countries. The Lancet, 377(9760), pp.139-146.
Polosa, R., Caponnetto, P., Morjaria, J.B., Papale, G., Campagna, D. and Russo, C., 2011. Effect
of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a
prospective 6-month pilot study. BMC public health, 11(1), p.786.
Sweanor, D., Alcabes, P. and Drucker, E., 2007. Tobacco harm reduction: how rational public
policy could transform a pandemic.
Taylor, A.H., Ussher, M.H. and Faulkner, G., 2007. The acute effects of exercise on cigarette
cravings, withdrawal symptoms, affect and smoking behaviour: a systematic
review. Addiction, 102(4), pp.534-543.
Zhou, X., Nonnemaker, J., Sherrill, B., Gilsenan, A.W., Coste, F. and West, R., 2009. Attempts
to quit smoking and relapse: factors associated with success or failure from the ATTEMPT
cohort study. Addictive behaviors, 34(4), pp.365-373.

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Appendix
Bibliography of selected review articles
Author(s) Year Journal (Source) Key Findings Notes
McRobbie, H., Bullen,
C., Hartmann-Boyce, J.
and Hajek, P.
2012 Cochrane Database Syst. Rev, 12. Smoking an electronic
cigarette containing
nicotine increased the
chances of smoking
cessation in long-term in
contrast to RC without
nicotine
ECs facilitate in smoking
cessation for long term in
comparison to the
placebo EC
Jha, P. and Peto, R. 2014 New England Journal of
Medicine, 370(1), pp.60-68.
The global impacts
associated with smoking
behavior, of quitting and
in relation to taxing
Life expectancy tends to
decrease with the
duration of smoking
among the concerned

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tobacco have been
vividly explained through
statistical records.
National trends in
tobacco-attributed
mortality spanning from
1950 to 2010 has been
stated for UK, US and
Poland.
individuals
Taylor, A.H., Ussher,
M.H. and Faulkner, G.
2007 Addiction, 102(4), pp.534-543. Management of cigarette
cravings as well as
withdrawal symptoms
may be done through
recommendation of
relatively small dose of
exercise
Smoking behavior may
be regulated by better
understanding of the
mechanisms that is linked
to smoking alongside
implementation of
effective and practical
methods of mitigation
Gorber, S.C., Schofield- 2009 Nicotine & tobacco Trends of gross Region specific accurate