National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Background

Tobacco is the single greatest cause of preventable deaths in the world.¹ The World Health Organization (WHO) estimates that tobacco causes more than five million premature deaths globally every year, a figure that could rise to eight million by 2030.¹ The Surgeon General of the United States has reported that smoking causes many different chronic diseases and cancers, harming almost every organ in the body; smoking in pregnancy causes maternal, fetal and infant deaths and disease; and there is no safe level of exposure to second-hand tobacco smoke.²

The age-standardised smoking prevalence among Aboriginal and Torres Strait Islander peoples is 2.8 times greater than for non-Indigenous Australians, with 39% of Aboriginal and Torres Strait Islander people aged 15 years and older reporting that they smoke daily in 2014–15.³ This prevalence has fallen from 49% in 2002, with a greater decline in non-remote than remote areas. More than half (57%) of Aboriginal and Torres Strait Islander children (0–14 years) live in a household with a person who smokes daily, and 13% live in a household where someone smokes inside.³ Aboriginal and Torres Strait Islander mothers had more than three times the age-standardised smoking prevalence during pregnancy (45%) than non-Indigenous mothers (13%) in 2014, having declined from 50% in 2009.⁴ Tobacco smoking was calculated to be responsible for 23% of the health gap between Aboriginal and Torres Strait Islander peoples and other Australians, and 12% of the total burden of disease for Aboriginal and Torres Strait Islander peoples in 2011.⁵

A national survey of 2522 people in 2012–13 found that the proportion of Aboriginal and Torres Strait Islander people who smoke daily and who reported wanting to quit (70% of all who smoke), making a quit attempt in the past year (48%), living in smoke-free homes (53%) and knowing about the most harmful effects of smoking (eg smoking causes lung cancer, 94%) was similar to that of the general population.⁶ However, a smaller proportion of Aboriginal and Torres Strait Islander people who smoke daily, compared to people who smoke daily in the general population, reported social norms disapproving of smoking (62% vs 79%) and had ever sustained a quit attempt for at least a month (47% vs 60%).^7,8

Smokeless tobacco, including native tobaccos such as pituri, continues to be chewed in Aboriginal and Torres Strait Islander communities, particularly in central Australia.⁹ Although there are little data from Australia, smokeless tobacco has been shown to cause cancers of the head and neck, oesophagus and pancreas in other countries.¹

Interventions

Australia has signed the WHO Framework Convention on Tobacco Control, the world’s first public health treaty, committing to a series of evidence-based national policies to reduce smoking and the harm it causes.¹⁰ Australia has implemented anti-tobacco mass media campaigns, pack warning labels, restrictions on tobacco advertising, price increases of tobacco through tax rises, smoke-free regulations and provided cessation services, contributing to Australia’s low national smoking prevalence.¹¹ There is some evidence that such population health approaches also motivate Aboriginal and Torres Strait Islander people who smoke to quit. Cross-sectional and longitudinal analyses of a large national survey demonstrated the impact of noticing anti-tobacco social marketing (eg TV advertisements and posters), with localised material having greater impact; of noticing pack warning labels; and of the introduction of plain packaging.^12,13 The proportion of Aboriginal and Torres Strait Islander people who smoke daily reporting smoke-free indoor workplaces (88%) and homes (56%) was similar to that of the general population.¹⁴ The evidence for the impact of tobacco tax rises on Aboriginal and Torres Strait Islander people who smoke is less clear.¹⁵

Health practitioners play a vital role in assisting and supporting smoking cessation and reducing the harms caused by smoking. At the health service level, instituting a practice system designed to identify and document tobacco use, such as a clinic screening system and the use of computer prompts, almost doubles the rate of health professional intervention and results in higher rates of cessation.^9,16

The 5As provide an evidence-based approach to smoking cessation for health professionals.¹⁰

Ask: Ask all patients if they smoke and ensure that their current smoking status is recorded in the medical record.¹⁰ Regularly – at least annually – update the smoking status in the medical records of anyone who smokes or has recently quit.¹⁶ A systematic approach to identifying all people who smoke should be used in every health service and has been shown to increase the support offered by health practitioners.¹⁷ Almost all (93%) Aboriginal and Torres Strait Islander people who smoke daily who had seen a health professional in the previous year reported being asked if they smoked, according to a national survey.¹⁸

Assess: Assess the willingness of people who smoke to quit and their nicotine dependence to guide treatment choices.^10,17,19,20 Smoking cessation advice should be sensitive to the patient’s preferences, needs and circumstances. There is no evidence that classifying people who smoke into the four stages of readiness to quit (pre-contemplation, contemplation, preparation, action and maintenance) is more useful than any other approach in smoking cessation. Assessment of nicotine dependence can be done using the six questions in the Fagerström test for nicotine dependence.²¹ A simpler assessment can be done by asking the following three questions:¹⁰

1. How soon after waking do you have your first cigarette?
2. How many cigarettes do you have each day?
3. Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms when you have tried to quit?

Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and withdrawal symptoms are indicators of nicotine dependence.

Advise: Advise all people who smoke to quit in a clear, non-confrontational way – for example, ‘The best thing you can do for your health is to quit the smokes’.¹⁰ This brief, repeated and consistent advice can increase smoking cessation rates (number needed to treat [NNT] with brief advice only = 50–120, based on a 2% unassisted quit rate at 12 months).^10,22 Such advice can be as brief as 30 seconds, but should be followed by offers of assistance to quit.¹⁶ More Aboriginal and Torres Strait Islander people who smoke daily and who have seen a health professional in the past year report that they have been advised to quit (75%), compared to a similar sample of all Australian people who smoke daily (56%).¹⁸ These Aboriginal and Torres Strait Islander people who smoke daily were 2.0 times more likely to have made a quit attempt in the past year than those who had not been advised to quit.

Assist: Assist smoking cessation with multiple sessions of individual, group, telephone or text messaging cessation support, and recommend smoking cessation pharmacotherapies to nicotine-dependent people who are interested in quitting.

There is a dose–response relationship between the total duration of face-to-face counselling and advice and successful cessation.¹⁷ There is no evidence that any particular behaviour change method is more effective than another, but the basic principles of setting a quit date, emphasising the importance of abstinence and providing multi-session support (preferably four or more sessions) should be adhered to.¹⁶ A meta-analysis of two randomised controlled trials (RCTs) at Aboriginal Community Controlled Health Services (ACCHSs) demonstrated that patients who were allocated to intensive counselling and support were 2.4 times more likely to successfully quit than patients who received usual care.²³

Quitline (phone 137 848 or 13QUIT) offers cessation counselling from trained Aboriginal and Torres Strait Islander counsellors who will call the person who smokes and proactively provide follow-up phone calls.¹⁰

Proactive services have been shown to be more effective than relying on the person who smokes to call Quitline.^10,16 Similarly, text-messaging services are effective in increasing smoking abstinence (eg QuitTxt; refer to ‘Resources’).²⁴ However, the evidence for internet-based quitting support is only promising but inconsistent, and there were no rigorous trials of smartphone apps that could be included in the latest Cochrane review.^10,25 The additional benefit of providing written self-help material (eg pamphlets) is minimal.¹⁰

In a large national survey, more Aboriginal and Torres Strait Islander people who had been advised to quit by a health professional reported being referred to Quitline (28%) or a quit-smoking website (27%) than to a quit course, group or clinic (16%). However, participants were more likely to follow through with the referrals to these courses, groups or clinics, and so more attended these than used either the Quitline or a website.¹⁸

Pharmacotherapies increase the effectiveness of smoking cessation counselling and should be offered to all dependent people who smoke who wish to quit, except those for whom there are medical contraindications.¹⁰ All three smoking cessation pharmacotherapies available in Australia (nicotine replacement therapy [NRT], varenicline and bupropion) have been shown to be effective in meta-analyses.^10,26 A recent Cochrane review found that monotherapy with varenicline or combining two types of NRT were the most effective forms of therapy.²⁶ However, a more recent large RCT found no difference between NRT patches and either varenicline or combination NRT.²⁷

Aboriginal and Torres Strait Islander people who smoke daily are less likely to use NRT and other smoking cessation therapies than non-Indigenous people who smoke, even though they are just as likely to believe that these therapies help people to quit.²⁸ These medicines can often be dispensed at no or reduced cost to Aboriginal and Torres Strait Islander patients, either through section 100 of the National Health Act 1953 in remote areas or elsewhere through the Closing the Gap PBS Co-Payment Programme.^29,30

Do not use varenicline or bupropion in women who smoke who are pregnant or breastfeeding.^10,16,31,32 There is insufficient evidence that NRT is effective in increasing smoking cessation in pregnancy, but if counselling has not been successful it may be reasonable to consider using intermittent oral NRT (eg inhaler or lozenges), after explanation of risks and benefits (NRT delivers lower doses of nicotine to the fetus and breast milk without the other toxins in tobacco smoke). Similarly, although there is inadequate evidence that NRT is effective in increasing cessation rates in young people, it may still be used following careful discussion with the patient and their carer if appropriate. Varenicline and bupropion, however, are not approved for use in people who smoke aged under 18 years.¹⁰

The benefit from ‘vaping’ e-cigarettes or electronic nicotine delivery systems (ENDS) in assisting quitting remains contentious. The use of e-cigarettes has been increasing in Australia; 31% of adults who smoke had used e-cigarettes in 2016, compared to 18% in 2013.³³ A 2016 Cochrane review found some evidence that e-cigarettes assist quitting, but no e-cigarettes have yet been approved by the Therapeutic Goods Administration (TGA) for this purpose, and in 2017 the National Health and Medical Research Council (NHMRC) recommended there was insufficient evidence for their use in cessation.³⁴ There is also insufficient evidence for other commonly used therapies: hypnotherapy, acupuncture and ‘Allen Carr’s Easyway’ method with private clinics run by people who have quit smoking by using this method.¹⁰

Arrange: Arrange follow-up visits to discuss and support progress. It is recommended that counselling continue for four visits and pharmacotherapy continue for 8–12 weeks. Relapse to smoking is common in the month following starting a quit attempt; however, there is no intervention shown to effectively reduce relapse.¹⁰