In the Northern Territory, several surveys since 1986 have documented remote community smoking rates ranging from 61–85%.4–6 These have remained relatively unchanged, particularly in the ‘Top End’. Clinicians working in remote communities face significant challenges to consistently deliver smoking interventions. These include rapid staff turnover, geographical isolation, and their principal obligation to provide acute patient care.7
To inform and encourage provision of smoking interventions by clinicians working in these settings, we describe the results of tobacco surveys in remote Northern Territory communities. The surveys provided a baseline for a 5 year tobacco study. Preliminary unpublished analysis of the recently completed follow up surveys demonstrates little change in smoking prevalence, but an increase in the number of smokers thinking about or actively trying to quit. This, along with the baseline survey results, reinforces the pressing need for clinicians to take every opportunity to encourage smoking cessation. We make practical recommendations, specifically for doctors working as part of primary healthcare teams, to support smokers wanting to change.
Method
Data for this study are derived from a multiple component, community action intervention and evaluation study to reduce tobacco smoking in three Aboriginal communities in the Top End of the Northern Territory.
Settings
Located in three corners of Arnhem Land, the populations of these communities range from 1100–1600 people. Comprised of more than 90% Aboriginal people, language and cultural practices largely remain intact. People living in these communities suffer extreme socioeconomic disadvantage. Geographical isolation further reduces access to many services. Strong social and historical factors have ‘normalised’ tobacco in everyday life, creating significant barriers to smoking cessation.8
Interviews and survey data
Community surveys were undertaken in 2008–09. Paid, local community members assisted the non-Indigenous research team with participant recruitment and data collection, described in detail elsewhere.9 The survey captured both qualitative and quantitative data in order to deepen understandings of local cultural and social contexts of tobacco use.
Quantitative data
Smoking status was recorded as ‘current’, ‘former’ (no tobacco use ≥6 months) or ‘never’ (including those who had tried once but had not taken it up). Daily tobacco consumption was assessed using questions about purchasing, sharing and personal use. Time-to-first-cigarette (TTFC) and cigarettes per day (CPD) assessed tobacco dependence.10 Self reported smoking status was confirmed using a handheld expired breath carbon monoxide monitor. Current smokers were asked to clarify any intentions about quitting (thinking, trying, not thinking). Former and current smokers were asked if they decided to quit with or without medical advice or support. Knowledge and use of cessation medicines, factors contributing to changing smoking, and whether participants restricted smoking in selected environments were documented.
Qualitative information
‘Current’ and ‘former’ smokers were invited to plot their tobacco journey from uptake to time of interview. Details of general concerns about tobacco use, quit attempts and relapse were recorded.
Free nicotine replacement therapy (NRT) in the form of patches (21 mg) and gum (2 mg and 4 mg) were offered (where appropriate) for participants to try, along with information about effective use.
Results
Tobacco users in the sample
The study sample comprised 15% of the total number of Indigenous population aged 16 years or over (400 participants). In the sample, 76% were current tobacco users with prevalence varying from 71% to 82% across communities. There was little difference between the proportion of males and females who were current users overall. Former users comprised 10% of the sample, while 14% had never used tobacco (Table 1).
Table 1. Tobacco use by gender, including patterns of use by gender among current smokers
| | Total sample (n=400) |
|---|
| Tobacco use | Female
n=194 | Male
n=206 | p value* |
|---|
| Never used tobacco |
31 (16%) |
23 (11%) |
0.337 |
| Former user |
18 (9%)† |
23 (11%)§ |
| Current user |
145 (75%)‡ |
160 (78%) |
| |
Current smokers (n=301) |
| Daily smoker (n=223/301) |
107 (76%) |
116 (73%) |
0.550 |
| Consumption (n=225)** |
| Smokes <10 cigarettes per day |
59 (54%) |
41 (35%) |
0.005 |
| Smokes >10 cigarettes per day |
50 (46%) |
75 (65%) |
| Time-to-first cigarette (n=291)** |
| After breakfast |
61 (45%) |
57 (37%) |
0.134 |
| First thing/during the night |
74 (55%) |
99 (63%) |
| Intentions toward smoking (n=297)** |
| Thinking about/trying to quit smoking |
91 (65%) |
125 (80%) |
0.005 |
| Not thinking about quitting |
49 (35%) |
32 (20%) |
* Pearson chi-square comparing proportions in each group and t-tests comparing mean age of first use in each age group
** Number of current and former smokers who provided this information
† Includes two women who were former users who exclusively chewed tobacco
‡ Includes four women in one community currently using tobacco who chewed but did not smoke it
§ Includes one former male user in one community who exclusively chewed tobacco |
Average age of first use among current users was 17 years (range 4–38 years), varying little between the communities (p=0.161) and between males and females (p=0.946). The average age of first use among current users in the younger age bracket (16–29 years) was consistently lower by 1.5–2 years than in users aged 30+ years.
Current smokers
The few users who exclusively chewed tobacco were excluded. Around 75% of the current smokers smoked daily (Table 1) with no differences in daily smoking between males and females across the communities. Daily use was often reported as constrained by lack of money on the ‘off’ pay week. Of those who provided details of daily consumption, 44% smoked <10 CPD. Generally, males were heavier smokers than females (p=0.005).
Among the current smokers, 291 provided information about TTFC. Of these, 41% reported that they had their first cigarette after breakfast or later. In data not shown, we found heavier smokers were almost three times more likely to smoke ‘first thing’ (p=0.001) and nine times more likely to smoke ‘during the night’ (p<0.001). However, it is noteworthy that one-third of those who smoked during the night or smoked first thing were lighter smokers.
Across the communities, 1 in 8 of the current smokers reported they were actively trying to quit or cut down at time of interview (Table 2): ‘Trying to wait at least 2 hours between smokes’. ‘I’m trying to quit. I go out bush to get away’. A further 60% reported they were thinking about quitting: ‘I want to quit – want to live long to see granddaughter’. ‘I’m thinking about quitting a little bit – I’m in footy training now’. The remaining 27% said they were not thinking about changing their smoking: ‘I can’t quit, it’s difficult; everyone will say we want to quit, but can’t’. ‘I can’t quit, I will smoke till I die’. Overall, females were around half as likely to report thinking about or actively trying to quit.
There was general willingness to try nicotine gum and patches. Several participants reported that patches did not adhere well to skin in humid conditions. Some participants reported that the gums reduced ‘starving for ngarali [tobacco]’, enabling reduced daily consumption.
Females were considerably more likely to restrict their smoking in selected environments, such as inside homes or cars (data not shown) (p=0.005): ‘I take the kids outside when I’m smoking’. ‘I smoke outside the house – my uncle had an operation so I don’t smoke around him’.
Overwhelmingly the most frequently mentioned concerns were regarding the impact of tobacco on health of self and/or others, children smoking and their young age of uptake: ‘Too many kids smoking – younger than me when I started’. ‘Children as young as 8–9 years starting to smoke’.
Table 2. Characteristics of the quit attempts made
| | Current (n=145) and former smokers (n=38) |
|---|
Female
n=79 | Male
n=104 | p value |
|---|
| Quit attempts (n=183)* |
| One only |
59 (75%) |
79 (76%) |
0.842 |
| More than one |
20 (25%) |
25 (24%) |
|
| Quit attempt informed by (n=154)* |
| Own decision without medical advice or support |
34 (58%) |
72 (77%) |
0.004 |
| Medical advice and/or diagnosed tobacco-related medical condition |
27 (44%) |
21 (23%) |
|
| Knowledge and use of cessation pharmacotherapies (n=158)* |
| Knew nothing about them |
24 (37%) |
36 (39%) |
|
| Knew about them but never used |
27 (42%) |
46 (49%) |
0.243 |
| Tried pharmacotherapies |
14 (22%) |
11 (12%) |
|
| * Number of current and former smokers who provided this information |
Quit attempts
Information about quit attempts was provided by 145 current and 38 former smokers. With very little difference between current and former smokers, these groups have been combined (Table 2). Females seemed more likely to attempt to quit with medical advice, males making their own decision. Less than a third of the current and former smokers knew about cessation medications and only 16% reported having ever tried them (Table 2). Medicines most frequently identified by participants were NRT patches and gums. Only three reported being prescribed varenicline, and all stated they had not felt confident to use it. Knowledge about how to use any of these medications effectively was rare.
Periods of both voluntary and enforced abstinence were regarded uniformly by participants as quit attempts and therefore have been reported as such, eg. lack of access to tobacco through bedridden hospitalisation or isolation from a retail outlet. Spending time on outstations away from the main community was perceived as a good opportunity to quit because of reduced access to tobacco, reduced cue exposure and more diversion opportunities: ‘I was stuck on the outstation in the wet season. Ran out of tobacco. I was eating well, hunting turtle and dugong, helps stay off the ngarali [tobacco]’.
Information about relapse was provided by 72 of those who made at least one quit attempt (data not shown). ‘Cue exposure’ was identified by 65% of these as the main reason for relapse, eg. ‘I came back to the community and I’m surrounded by smokers’ and ‘My wife and friends all smoke, so it’s too hard to give up’.
Motivators to quit
Of the 145 current smokers who had made at least one quit attempt, 134 provided information about motivators to quit. Major motivators in descending frequency of mention include:
- concern about a diagnosed chronic or acute health condition or physical sign, such as shortness of breath
- lack of access to tobacco
- pregnancy
- advised by a doctor to quit (neither nurses nor Indigenous health workers [IHWs] were reported as having provided this advice)
- concern for future health
- role model, particularly as a parent but also as a health worker
- wanting to increase fitness
- demand sharing pressures
- death in the family
- social marketing
- cost.
Discussion
Community based approaches have been advocated to promote health and prevent disease, particularly those that emphasise changing social norms.11 With extraordinary rates of smoking in these populations, we advise that interventions by clinicians at the individual level are more likely to be successful if part of a range of concurrent community based intervention components. Recent research has identified the need to improve the uptake of secondary preventive strategies such as brief interventions.12 Offering assistance with quitting is more effective than merely advice to quit.13 Among the current and former smokers it was evident that doctors played an important role in motivating smokers to quit. Because smoking journeys were long, quit attempts were recounted by participants as having occurred over the past 40 years, indicating that the work of doctors has been a consistent, long term force for change in these settings.14
While biofeedback has been found to have limited impact on increasing cessation,15 the carbon monoxide monitor was found to be a consistently useful tool to engage survey participants and other members of these communities in brief interventions.
Time-to-first cigarette, including waking through the night, is an indicator of dependence which may require more intense levels of treatment.10 This study showed that even light smokers woke during the night for a cigarette, possibly reflecting the impact of environmental factors, such as overcrowding with consequent disturbed sleep, rather than nicotine withdrawal, per se. Thorough exploration of compulsion to use and presence of withdrawal symptoms before prescribing cessation medications is recommended.16
A 2008 Australian survey (n=697) revealed that 45.6% of quitters used cessation medications,17 a considerably higher proportion than found in these communities. Despite their reported readiness for change, smokers in the study communities had little knowledge of cessation methods or medications. This raises issues of both access and awareness. More time may be needed to ensure that patients understand effective treatment regimens. Less dependent smokers may benefit from short acting NRT which is not readily available.18 When prescribing varenicline, potential risks should be weighed up against cessation benefits, and patients asked to immediately report adverse effects.19
Follow up is an important feature of relapse prevention, both to address prolonged withdrawal symptoms and develop relapse prevention strategies.20 Initial follow up should be within the first week,21 which may entail a home visit. Local IHWs or ‘tobacco workers’ may be able to assist. Engaging in reciprocal learning approaches with local IHWs should contribute to the adaptation of cessation interventions to suit the cultural context.7 Cue exposure was cited as the major reason for relapse. In other settings, smoke free homes encourage quit attempts and reduce relapse.22 Advocacy for smoke free homes and other environments has generally been well received over the life of the project.23
Among the general population in Australia, the main motivators for changing smoking have been concerns about health impacts and the financial cost.1 In our baseline surveys, while health concerns were also a major motivator, cost ranked last, perhaps because daily consumption is about half that of the general Indigenous population,2 and therefore less of a financial burden. Highly ranked motivators included pregnancy and advice by a doctor. Antenatal presentations provide a major opportunity to engage in brief interventions that should be well received. Lack of access to tobacco was a major factor in quit attempts and those embarking on cessation may be encouraged to spend some time on an outstation in the early weeks.
Limitations
The study sample was not randomly selected so results cannot be generalised. However, participants were opportunistically recruited and reflected age and gender balances of each community.
Recommendations and conclusions
We refer readers to the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people,24 and offer our own recommendations for practice, with examples shown in Table 3. Despite high rates of tobacco use, there is a great readiness for change, with more than half of smokers thinking about or actively trying to quit. Health concerns, including pregnancy, are the major motivator for quitting. With cue exposure cited as the major cause for relapse, smoke-free homes should be promoted, both as a strategy to aid cessation and to decrease health impacts on other family members. There is a need for improved access and awareness of cessation medications. Finally, it is clear that GPs working in primary healthcare teams in these remote populations are well placed to make a significant impact on the extremely high rates of smoking.
Table 3. Practice points and examples for clinicians undertaking tobacco interventions in remote community settings
| Recommended practice points | Practical examples |
|---|
| Record the smoking status of all patients |
This may be systematically collected through adult health checks or other routine screening processes. (National recommendations are to screen patients aged 10 years or over for smoking history) |
| Make the most of every opportunity to engage all smokers in brief interventions |
Ask patients if they have any concerns about smoking. Results from the breath carbon monoxide monitor can open the doorway to brief interventions (eg. discussing the presence of invisible poisons from the burning cigarette and that carbon monoxide is only one of thousands of poisons in tobacco smoke). Offer cessation support as well as quit advice |
| Engage with pregnant women who are smokers |
Many clinics do not have on-site midwives. IHWs, particularly those working in women’s business as either clinic based health workers or community educators, should have thorough knowledge of tobacco related harms and cessation support, including medications |
| Establish the patient has a clear understanding of how to use cessation medications effectively |
This may involve simple but thorough explanations of the process of addiction, particularly if prescribing NRT (eg. talking about craving in terms of the brain starving for nicotine). A health worker may assist with interpretation and also confirm or clarify the patient’s understandings |
| Be prepared to discuss tobacco use within the local cultural context |
How is tobacco used? Is it chewed or smoked? In parts of Arnhem Land there are strong cultural connections to tobacco, including ceremonial obligations that would need acknowledgement in treatment plans. Find a cultural mentor who will explain these matters. Are there community based or visiting tobacco workers you can liaise with? |
| Actively promote the benefits of smoke-free environments, particularly homes and cars |
Discuss the idea of not sharing poisons with other non-smoking family members, especially babies, small children and the frail elderly. If family members are trying to quit, a smoke-free home is the rest of the family’s commitment to supporting a healthy choice. Have signage or posters on hand that can be placed in homes. Often families shifting into new houses are interested in starting out with smoke-free rules |
Competing interests: None.
Ethics approval: Human Research Ethics Committees of the NT Department of Health and Families and Menzies School of Health Research and James Cook University.
Provenance and peer review: Not commissioned; externally peer reviewed.
Acknowledgements
The authors acknowledge the diversity of Indigenous peoples in Australia and the problematic nature of attempting to adequately reflect that diversity with suitable terminology. In this article, the use of the term ‘Indigenous’, unless otherwise evident by the context of its use, should be taken to include Aboriginal and Torres Strait Islander peoples.
The project was funded by the NHMRC (project grant #436012).
The research team would like to acknowledge the contribution to the Top End Tobacco Project made by members of the participating Arnhem Land communities.