Citation

Swift, E., Borland, R., Cummings, K.M., Fong, G.T., McNeill, A., Hammond, D., Thrasher, J.F., Partos, T.R., Yong, H.H. (2015). Australian smokers’ support for plain or standardised packs before and after implementation: Findings from the ITC Four Country Survey. Tobacco Control, 24(6), 16-21.

Abstract

Background: Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity.

Methods: A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013).

Results: Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity.

Conclusions: Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

Citation

Kasza, K.A., Cummings, K.M., Carpenter, M.J., Cornelius, M.E., Hyland, A., Fong, G.T. (2015). Use of stop-smoking medications in the United States before and after the introduction of varenicline. Addiction, 110(2), 346-355.

Abstract

Aims: To evaluate trends in use of stop-smoking medications (SSMs) before and after varenicline (Chantix™) was introduced to the market-place in the United States, and to determine whether varenicline reached segments of the population unlikely to use other SSMs.

Design: Cohort survey.

Setting: United States.

Participants: A nationally representative sample of adult smokers in the United States interviewed as part of the International Tobacco Control Four Country Survey between 2004 and 2011. Primary analyses used cross-sectional data from 1737 smokers who attempted to quit (∼450 per wave).

Measurements: Reporting an attempt to quit smoking; use of each of the following types of SSMs for the purpose of quitting smoking: nicotine gum, nicotine patch, other nicotine replacement therapy, bupropion and varenicline.

Findings: There was a significant increase in the rate of use of any SSM among quit attempters across the study period [odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.10-1.21 per year]. This increase was largest after varenicline was introduced (OR = 1.16, 95% CI = 1.07-1.26 per year); however, there was a decline in nicotine patch use during this time (OR = 0.87, 95% CI = 0.76-0.99 per year). Varenicline users were generally similar to users of other SSMs but differed from those who did not use any SSMs, in that they tended to be older (OR = 5.46, P = 0.024), to be white (OR = 2.33, P = 0.002), to have high incomes (OR = 1.85, P = 0.005), to have high nicotine dependence prior to quitting (OR = 2.40, P = 0.001) and to have used medication in the past (OR = 3.29, P < 0.001).

Conclusions: The introduction of varenicline in the United States coincided with a net increase in attempts to quit smoking and, among these, a net increase in use of stop-smoking medications. The demographic profile of varenicline users is similar to the profile of those who use other stop-smoking medications and different from the profile of those who attempt to quit without any medication .

Citation

Cornelius, M.E., Cummings, K.M., Fong, G.T., Hyland, A., Driezen, P., Chaloupka, F., Hammond, D., O’Connor, R.J., Bansal-Travers, M. (2015). The prevalence of brand switching among adult smokers in the USA, 2006-2011: Findings from the ITC US Surveys. Tobacco Control, 24(6), 609-615.

Abstract

Background: Recent studies have suggested that about 1 in 5 smokers report switching brands per year. However, these studies only report switching between brands. The current study estimated the rates of switching both within and between brand families and examining factors associated with brand and brand style switching.

Methods: Data for this analysis are from the International Tobacco Control 2006-2011 US adult smoker cohort survey waves 5-8 (N=3248). A switch between brands was defined as reporting two different cigarette brand names for two successive waves, while switching within brand was defined as reporting the same brand name, but a different brand style. Repeated measures regression was used to determine factors associated with both switch types.

Results: A total of 1475 participants reported at least two successive waves of data with complete information on brand name and style. Overall switching increased from 44.9% in 2007-2008 to 58.4% in 2010-2011. Switching between brand names increased from 16% to 29%, while switches within the same brand name to a different style ranged from 29% to 33%. Between-brand switching was associated with younger age, lower income, non-white racial group and use of a discount brand, whereas, within-brand switching was associated with younger age and the use of a premium brand cigarette.

Conclusions: Nearly half of smokers in the USA switched their cigarette brand or brand style within a year. Switching between brands may be more price motivated, while switching within brands may be motivated by price and other brand characteristics such as product length.

Citation

Li, L., Borland, R., Yong, H.H., Prohmmo, A., Thrasher, J.F., Hitchman, S.C., Fong, G.T., Hammond, D., Bansal-Travers, M. (2015). Longer term impact of cigarette package warnings in Australia compared to the United Kingdom and Canada: Findings from the International Tobacco Control (ITC) Four Country Survey. Health Education Research, 30(1), 67-80.

Abstract

This study examines the effects of different cigarette package warnings in Australia, Canada and the United Kingdom up to 5 years post-implementation. The data came from the International Tobacco Control Surveys. Measures included salience of warnings, cognitive responses, forgoing cigarettes and avoiding warnings. Although salience of the UK warnings was higher than the Australian and Canadian pictorial warnings, this did not lead to greater levels of cognitive reactions, forgoing or avoiding. There was no difference in ratings between the Australian and UK warnings for cognitive responses and forgoing, but the Canadian warnings were responded to more strongly. Avoidance of the Australian warnings was greater than to UK ones, but less than to the Canadian warnings. The impact of warnings declined over time in all three countries. Declines were comparable between Australia and the United Kingdom on all measures except avoiding, where Australia had a greater rate of decline; and for salience where the decline was slower in Canada. Having two rotating sets of warnings does not appear to reduce wear-out over a single set of warnings. Warning size may be more important than warning type in preventing wear-out, although both probably contribute interactively.

Citation

Hummel, K., Hoving, C., Nagelhout, G.E., de Vries, H., van den Putte, B., Candel, M.J.J.M., Borland, R., Willemsen, M.C. (2015). Prevalence and reasons for use of electronic cigarettes among smokers: Findings from the International Tobacco Control (ITC) Netherlands Survey. International Journal of Drug Policy, 26(6), 601-608.

Abstract

Background: Not much is known about how people in the Netherlands respond to electronic cigarettes (ecigarettes); how many know about them, which people try them, keep using them and why, and what are changes over time regarding awareness and use?

Methods: We used samples of smokers aged 15 years and older from 2008 (n = 1,820), 2010 (n = 1,702), 2013 (n = 1,530), and 2014 (n = 1,550) as part of the International Tobacco Control (ITC) Netherlands Survey. Reasons for use and characteristics of smokers were examined using the sample from 2014. Logistic regression analyses were conducted to evaluate the associations between smoking-related variables with ever trying e-cigarettes and current e-cigarette use.

Results: In 2014, 91.4% of Dutch smokers reported being aware of e-cigarettes (97.1% in 2008, 89.2% in 2010, and 85.5% in 2013), 40.0% reported having ever tried them (13.4% in 2008, 14.5% in 2010, and 19.6% in 2013), and 15.9% were currently using them (4.0% in 2008, 1% in 2010, and 3.9% in 2013). The main reason given for using e-cigarettes was to reduce the number of regular cigarettes smoked per day (79%). Ever trying e-cigarettes among those aware of e-cigarettes was associated with being young, smoking more regular cigarettes per day, having made a quit attempt in the last year, having used smoking cessation pharmacotherapy in the last year, and reporting high awareness of the price of regular cigarettes. Smokers who kept using e-cigarettes had a higher educational background, had higher harm awareness for the health of others, and were less likely to have a total smoking ban at home.

Conclusion: E-cigarettes are increasingly used by Dutch smokers. Commonly endorsed motivations for current e-cigarette use were to reduce tobacco smoking and because e-cigarettes are considered to be less harmful than tobacco cigarettes.

Citation

Wu, C., Thompson, M.E., Fong, G.T., Jiang, Y., Yang, Y., Feng, G., Quah, A.C.K. (2015). Methods of the International Tobacco Control (ITC) China Survey: Waves 1, 2, and 3. Tobacco Control, 24(Suppl 4), iv1-iv5.

Abstract

This paper describes the methods of sampling design and data collection of waves 1, 2 and 3 of the International Tobacco Control (ITC) China Survey, with major focus on longitudinal features of the study. Key measures of quality of the survey data, such as retention rates and final sample sizes, are presented. Sample replenishment procedures are outlined, including the addition of a new city, Kunming, at wave 3. Methods for constructing the longitudinal and cross-sectional survey weights are briefly described.

Citation

Azagba, S., Burhoo, P., Chaloupka, F., Fong, G.T. (2015). Effect of cigarette tax increase in combination with mass media campaign on smoking behaviour in Mauritius: Findings from the ITC Survey. Tobacco Control, 24(Suppl 3), iii71-iii75.

Abstract

Background: Mauritius has made great strides in adopting evidence-based tobacco control measures, including an increase in its cigarette excise tax and antitobacco mass media (Sponge) campaign. The primary objective of this study is to examine the combined effect of these measures on smoking behaviour.

Methods: This study used longitudinal data from the International Tobacco Control Mauritius Survey, 2009-2011. Waves 1 and 2 were conducted before the tax increase and wave 3 was conducted shortly after the Sponge campaign and 6 months after the cigarette excise tax increase. Generalised estimating equations were used to examine the effects of these two key tobacco control measures on smoking prevalence and the quantity of cigarettes smoked.

Results: The results showed that the combination of cigarette tax increase and the Sponge campaign had a significantly negative effect on the prevalence of smoking in Mauritius and the number of cigarettes smoked among continuing smokers. Specifically, the measures significantly reduced the odds of being a smoker (adjusted OR 0.88, 95% CI 0.81 to 0.97). For average daily cigarettes smoked, the measures had a significant reduction in cigarettes per day by about 6% (incidence rate ratios 0.94, 95% CI 0.89 to 0.99).

Conclusions: The combination of policy measures significantly reduced the consumption of cigarettes in Mauritius. While these results are encouraging, these efforts must be part of a sustained effort to further reduce the smoking prevalence in Mauritius .

Citation

Shang, C., Chaloupka, F., Fong, G.T., Thompson, M.E., Siahpush, M., Ridgeway, W. (2014, June). Weight control belief and its impact on cigarettes consumption and quit attempts: Findings from the ITC Project. Oral presentation at the American Society of Health Economists Conference, Los Angeles, California, United States.

Abstract

Background: Weight concerns are widely documented as one of the major barriers for girls and young adult women to quit smoking. Therefore, it is important to investigate whether smokers who have weight concerns respond to tobacco control policies differently than smokers who do not in terms of quit attempts, and how this difference varies by gender and country.

Objective: This study aims to investigate, by gender and country, whether smokers who believe that smoking helps control weight are less responsive to tobacco control policies with regards to quit attempts than those who do not.

Methods: We use longitudinal data from the International Tobacco Control Policy Evaluation Project in the USA, Canada, the UK and Australia to conduct the analysis. We first constructed a dichotomous indicator for smokers who have the weight control belief and then examined the disparity in policy responsiveness in terms of quit attempts by directly estimating the interaction terms of policies and the weight control belief indicator using generalised estimating equations.

Findings: We find that weight control belief significantly attenuates the policy impact of tobacco control measures on quit attempts among US female smokers and among UK smokers. This pattern was not found among smokers in Canada and Australia.

Conclusions: Although our results vary by gender and country, the findings suggest that weight concerns do alter policy responsiveness in quit attempts in certain populations. Policy makers should take this into account and alleviate weight concerns to enhance the effectiveness of existing tobacco control policies on promoting quitting smoking.

Citation

Liber, A.C., Ross, H., Omar, M., Chaloupka, F. (2015). The impact of the Malaysian minimum cigarette price law: Findings from the ITC Malaysia Survey. Tobacco Control, 24(Suppl 3), iii83-iii87.

Abstract

Objectives: Study the effects of the 2011 Malaysian minimum price law (MPL) on prices of licit and illicit cigarette brands. Identify barriers to the MPL achieving positive public health effects.

Methods: The International Tobacco Control Project's Southeast Asia survey collected information on Malaysian smokers' cigarette purchases (n=7520) in five survey waves between 2005 and 2012. Consumption-weighted comparisons of proportions tests and adjusted Wald tests were used to evaluate changes over time in violation rates of the inflation-adjusted MPL, the proportion of illicit cigarette purchases and mean prices.

Results: After the passage of the MPL, the proportion of licit brand cigarette purchases that were below the inflation-adjusted 2011 minimum price level fell substantially (before 3.9%, after 1.8%, p=0.002), while violation of the MPL for illicit brand cigarette purchases was unchanged (before 89.8%, after 91.9%, p=0.496). At the same time, the mean real price of licit cigarettes rose (p=0.006), while the mean real price of illicit cigarettes remained unchanged (p=0.134). The proportion of illicit cigarette purchases rose as well (before 13.4%, after 16.5%, p=0.041).

Discussion: The MPL appears not to have meaningfully changed cigarette prices in Malaysia, as licit brand prices remained well above and illicit brand prices remained well below the minimum price level before and after MPL's implementation. The increasing proportion of illicit cigarettes on the market may have undermined any positive health effects of the Malaysian MPL. The illicit cigarette trade must be addressed before a full evaluation of the Malaysian MPL's impact on public health can take place. The authors encourage the continued use of specific excise tax increases to reliably increase the price and decrease the consumption of cigarettes in Malaysia and elsewhere.

Citation

Curti, D., Shang, C., Ridgeway, W., Chaloupka, F., Fong, G.T. (2015). The use of legal, illegal, and roll-your-own cigarettes to increasing tobacco excise taxes and comprehensive tobacco control policies: Findings from the ITC Uruguay Survey. Tobacco Control, 24(Suppl 3), iii17-iii24

Abstract

Background: Little research has been done to examine whether smokers switch to illegal or roll-yourown (RYO) cigarettes in response to a change in their relative price.

Objective: This paper explores how relative prices between three cigarette forms (manufactured legal, manufactured illegal and RYO cigarettes) are associated with the choice of one form over another after controlling for covariates, including sociodemographic characteristics, smokers' exposure to antismoking messaging, health warning labels and tobacco marketing.

Methods: Generalised estimating equations were employed to analyse the association between the price ratio of two different cigarette forms and the usage of one form over the other.

Findings: A 10% increase in the relative price ratio of legal to RYO cigarettes is associated with a 4.6% increase in the probability of consuming RYO cigarettes over manufactured legal cigarettes (p≤0.05). In addition, more exposure to antismoking messaging is associated with a lower odds of choosing RYO cigarettes over manufactured legal cigarettes (p≤0.05). Non-significant associations exist between the manufactured illegal to legal cigarette price ratios and choosing manufactured illegal cigarettes, suggesting that smokers do not switch to manufactured illegal cigarettes as prices of legal ones increase. However, these non-significant findings may be due to lack of variation in the price ratio measures. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers need to narrow price variability in the tobacco market. Moreover, increasing antismoking messaging reduces tax avoidance in the form of switching to cheaper RYO cigarettes in Uruguay.

Citation

Shang, C., Chaloupka, F.J., Fong, G.T., Thompson, M.E., O'Connor, R. (2015). The association between tax structure and cigarette price variability: Findings from the International Tobacco Control Policy Evaluation (ITC) Project. Tobacco Control, 24(Suppl 3), iii88-iii93.

Abstract

Background: Recent studies have shown that more opportunities exist for tax avoidance when cigarette excise tax structure departs from a uniform specific structure. However, the association between tax structure and cigarette price variability has not been thoroughly studied in the existing literature.

Objective: To examine how cigarette tax structure is associated with price variability. The variability of self-reported prices is measured using the ratios of differences between higher and lower prices to the median price such as the IQR-to-median ratio.

Methods: We used survey data taken from the International Tobacco Control Policy Evaluation (ITC) Project in 17 countries to conduct the analysis. Cigarette prices were derived using individual purchase information and aggregated to price variability measures for each surveyed country and wave. The effect of tax structures on price variability was estimated using Generalised Estimating Equations after adjusting for year and country attributes.

Findings: Our study provides empirical evidence of a relationship between tax structure and cigarette price variability. We find that, compared to the specific uniform tax structure, mixed uniform and tiered (specific, ad valorem or mixed) structures are associated with greater price variability (p≤0.01). Moreover, while a greater share of the specific component in total excise taxes is associated with lower price variability (p≤0.05), a tiered tax structure is associated with greater price variability (p≤0.01). The results suggest that a uniform and specific tax structure is the most effective tax structure for reducing tobacco consumption and prevalence by limiting price variability and decreasing opportunities for tax avoidance.

Citation

Huang, J., Zheng, R., Chaloupka, F., Fong, G.T., Li, Q., Jiang, Y. (2015). Differential responsiveness to cigarette price by education and income among adult urban Chinese smokers. Tobacco Control, 24(Suppl 3), iii76-iii82.

Abstract

Background: Few studies have examined the impact of tobacco tax and price policies in China. In addition, very little is known about the differential responses to tax and price increases based on socioeconomic status in China.

Objective: To estimate the conditional cigarette consumption price elasticity among adult urban smokers in China and to examine the differential responses to cigarette price increases among groups with different income and/or educational levels.

Methods: Multivariate analyses employing the general estimating equations method were conducted using the first three waves of the International Tobacco Control (ITC) China Survey. Analyses based on subsample by education and income were conducted.

Findings: Conditional cigarette demand price elasticity ranges from −0.12 to −0.14. No differential responses to cigarette price increase were found across education levels. The price elasticity estimates do not differ between high-income smokers and medium-income smokers. Cigarette consumption among low-income smokers did not decrease after a price increase, at least among those who continued to smoke.

Conclusions: Relative to other low-income and middle-income countries, cigarette consumption among Chinese adult smokers is not very sensitive to changes in cigarette prices. The total impact of cigarette price increase would be larger if its impact on smoking initiation and cessation, as well as the pricereducing behaviours such as brand switching and trading down, were taken into account.

Citation

Thomas, D.P., Davey, M.E., Briggs, V., Borland, R. (2015). Talking About the Smokes: Summary and key findings. Medical Journal of Australia, 202(10), S3-4.

There is no abstract available for this publication.

Citation

Nicholson, A.K., Borland, R., Davey, M.E., Stevens, M., Thomas, D.P. (2015). Past quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S20-25.

Abstract

Objectives: To describe past attempts to quit smoking in a national sample of Aboriginal and Torres Strait Islander people, and to compare their quitting activity with that in the general Australian population.

Design, setting and participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 smokers and 78 recent quitters between April 2012 and October 2013. Baseline results for daily smokers (n = 1392) are compared with results for daily smokers (n = 1655) from Waves 5 to 8.5 (2006–2012) of the Australian International Tobacco Control Policy Evaluation Project (ITC Project).

Main outcome measures: Ever having tried to quit, tried to quit in the past year, sustained a quit attempt for 1 month or more.

Results: Compared with the general population, a smaller proportion of Aboriginal and Torres Strait Islander daily smokers had ever tried to quit (TATS, 69% v ITC, 81.4%), but attempts to quit within the past year were similar (TATS, 48% v ITC, 45.7%). More Aboriginal and Torres Strait Islander daily smokers than those in the general population reported sustaining past quit attempts for short periods only. Aboriginal and Torres Strait Islander smokers whose local health services had tobacco control resources were more likely to have tried to quit, whereas men and people who perceived they had experienced racism in the past year were less likely. Younger smokers, those who had gone without essentials due to money spent on smoking, and those who were often unable to afford cigarettes were more likely to have tried to quit in the past year, but less likely to have ever sustained an attempt for 1 month or more. Smokers who were unemployed, those who had not completed Year 12 and those from remote areas were also less likely to sustain a quit attempt.

Conclusions: Existing comprehensive tobacco control programs appear to be motivating Aboriginal and Torres Strait Islander smokers to quit but do not appear to overcome challenges in sustaining quit attempts, especially for more disadvantaged smokers and those from remote areas.

Citation

Couzos, S., Nicholson, A.K., Hunt, J.M., Davey, M.E., May, J.K., Bennet, P.T., Westphal, D.W., Thomas, D.P. (2015). Talking About the Smokes: A large-scale, community-based participatory research project. Medical Journal of Australia, 202(10), S13-19.

Abstract

Objective: To describe the Talking About The Smokes (TATS) project according to the World Health Organization guiding principles for conducting community-based participatory research (PR) involving indigenous peoples, to assist others planning large-scale PR projects.

Design, setting and participants: The TATS project was initiated in Australia in 2010 as part of the International Tobacco Control Policy Evaluation Project, and surveyed a representative sample of 2522 Aboriginal and Torres Strait Islander adults to assess the impact of tobacco control policies. The PR process of the TATS project, which aimed to build partnerships to create equitable conditions for knowledge production, was mapped and summarised onto a framework adapted from the WHO principles.

Main outcome measures: Processes describing consultation and approval, partnerships and research agreements, communication, funding, ethics and consent, data and benefits of the research. Results: The TATS project involved baseline and follow-up surveys conducted in 34 Aboriginal community-controlled health services and one Torres Strait community. Consistent with the WHO PR principles, the TATS project built on community priorities and strengths through strategic partnerships from project inception, and demonstrated the value of research agreements and trusting relationships to foster shared decision making, capacity building and a commitment to Indigenous data ownership.

Conclusions: Community-based PR methodology, by definition, needs adaptation to local settings and priorities. The TATS project demonstrates that large-scale research can be participatory, with strong Indigenous community engagement and benefits.

Citation

Thomas, D.P., Panaretto, K.S., Stevens, M., Bennet, P.T., Borland, R. (2015). Smoke-free homes and workplaces of a national sample of Aboriginal and Torres Strait Islander people. Medical Journal of Australia, 202(10), S33-38.

Abstract

Objective: To examine Aboriginal and Torres Strait Islander people's protection from second-hand smoke at home and work.

Design, Setting and Participants: The Talking About The Smokes project surveyed 2522 Aboriginal and Torres Strait Islander people from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait, using quota sampling, from April 2012 to October 2013. We made comparisons with data from Australian smokers in the International Tobacco Control Policy Evaluation Project (ITC Project), collected from either July 2010 to May 2011 or September 2011 to February 2012. MAIN OUTCOME

Measures: Whether smoking was not allowed anywhere in the home, or not allowed in any indoor area at work.

Results: More than half (56%) of Aboriginal and Torres Strait Islander smokers and 80% of nonsmokers reported that smoking was never allowed anywhere in their home. Similar percentages of daily smokers in our sample and the Australian ITC Project data reported bans. Most employed Aboriginal and Torres Strait Islander daily smokers (88%) reported that smoking was not allowed in any indoor area at work, similar to the Australian ITC Project estimate. Smokers working in smoke-free workplaces were more likely to have smoke-free homes than those in workplaces where smoking was allowed indoors (odds ratio, 2.85; 95% CI, 1.67-4.87). Smokers who lived in smoke-free homes were more likely to have made a quit attempt in the past year, to want to quit, and to have made quit attempts of 1 month or longer.

Conclusion: Most Aboriginal and Torres Strait Islander people are protected from second-hand smoke at work, and similar proportions of Aboriginal and Torres Strait Islander smokers and other Australian smokers do not allow smoking inside their homes.

Citation

Thomas, D.P., Panaretto, K.S., Stevens, M., Borland, R. (2015). Dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers. Medical Journal of Australia, 202(10), S39-44.

Abstract

Objectives: To examine indicators of nicotine dependence in a national sample of Aboriginal and Torres Strait Islander daily smokers and their association with sustaining a quit attempt for at least 1 month, and to make comparisons with a national sample of Australian daily smokers.

Design, Setting and Participants: The Talking About The Smokes project used a quota sampling design to recruit 1392 daily smokers from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait from April 2012 to October 2013. These were compared with 1010 daily smokers from the general Australian population surveyed by the International Tobacco Control Policy Evaluation Project from September 2011 to February 2012.

Main Outcome Measures: Cigarettes per day (CPD), time to first cigarette, Heaviness of Smoking Index (HSI), other indicators of dependence, and whether smokers had ever sustained a quit attempt for at least 1 month.

Results: There was little difference in the mean HSI scores for Aboriginal and Torres Strait Islander and other Australian daily smokers. A higher proportion of Aboriginal and Torres Strait Islander daily smokers smoked ≤ 10 CPD (40% v 33.4%), but more also smoked their first cigarette within 30 minutes of waking (75% v 64.6%). Lower proportions of Aboriginal and Torres Strait Islander smokers reported having strong urges to smoke at least several times a day (51% v 60.7%) or that it would be very hard to quit (39% v 47.9%). Most Aboriginal and Torres Strait Islander smokers reported experiencing difficulties during their most recent quit attempt. All indicators of dependence, except CPD and strong urges, were positively associated with not having made a sustained quit attempt. Reported difficulties during the most recent quit attempt were more strongly associated with being unable to sustain quit attempts than were traditional measures of dependence.

Conclusion: Aboriginal and Torres Strait Islander smokers' experiences of past attempts to quit may be more useful than conventional indicators of nicotine dependence in understanding their dependence.

Citation

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 of Australia, 202(10), S45-50.

Abstract

Objectives: To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting.

Design, Setting and Participants: The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013.

Main Outcome Measures: Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit.

Results: Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not.

Conclusion: Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.

Citation

Nicholson, A.K., Borland, R., Bennet, P.T., Van der Sterren, A.E., Stevens, M., Thomas, D.P. (2015). Personal attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters. Medical Journal of Australia, 202(10), S51-56.

Abstract

Objectives: To describe attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters and assess how they are associated with quitting, and to compare these attitudes with those of smokers in the general Australian population.

Design, Setting, and Participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers and 78 recent quitters from April 2012 to October 2013.

Main Outcome Measures: Personal attitudes towards smoking and quitting, wanting to quit, and attempting to quit in the past year.

Results: Aboriginal and Torres Strait Islander daily smokers were less likely than daily smokers in the general Australian population to report enjoying smoking (65% v 81%) and more likely to disagree that smoking is an important part of their life (49% v 38%); other attitudes were similar between the two groups. In the Aboriginal and Torres Strait Islander sample, non-daily smokers generally held less positive attitudes towards smoking compared with daily smokers, and ex-smokers who had quit within the past year reported positive views about quitting. Among the daily smokers, 78% reported regretting starting to smoke and 81% reported spending too much money on cigarettes, both of which were positively associated with wanting and attempting to quit; 32% perceived smoking to be an important part of their life, which was negatively associated with both quit outcomes; and 83% agreed that smoking calms them down when stressed, which was not associated with the quitting outcomes.

Conclusions: Aboriginal and Torres Strait Islander smokers were less likely than those in the general population to report positive reasons to smoke and held similar views about the negative aspects, suggesting that factors other than personal attitudes may be responsible for the high continuing smoking rate in this population.

Citation

Nicholson, A.K., Borland, R., Van der Sterren, A.E., Bennet, P.T., Stevens, M., Thomas, D.P. (2015). Social acceptability and desirability of smoking in a national sample of Aboriginal and Torres Strait Islander people. Medical Journal of Australia, 202(10), S57-62.

Abstract

Objectives: To describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander people, and to assess the relationship of these beliefs with quitting.

Design, setting and participants: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 nondaily smokers, 311 exsmokers and 568 never-smokers from April 2012 to October 2013.

Main outcome measures: Eight normative beliefs about smoking; wanting and attempting to quit.

Results: Compared with daily smokers in the general Australian population, Aboriginal and Torres Strait Islander daily smokers were less likely to report that mainstream society disapproves of smoking (78.5% v 62%). Among Aboriginal and Torres Strait Islander daily smokers, 40% agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking, 70% said there are increasingly fewer places they feel comfortable smoking, and most (90%) believed non-smokers set a good example to children. Support for the government to do more to tackle the harm caused by smoking was much higher than in the general Australian population (80% v 47.2%). These five normative beliefs were all associated with wanting to quit. Non-smokers reported low levels of pressure to take up smoking.

Conclusion: Tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.

Citation

Davey, M.E., Hunt, J.M., Foster, R., Couzos, S., Van der Sterren, A.E., Sarin, J., Thomas, D.P. (2015). Tobacco control policies and activities in Aboriginal community-controlled health services. Medical Journal of Australia, 202(10), S63-66.

Abstract

Objectives: To describe tobacco control policies and activities at a nationally representative sample of Aboriginal community-controlled health services (ACCHSs).

Design, Setting, and Participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit 34 ACCHSs around Australia. Between April 2012 and October 2013, a representative at each ACCHS completed a survey about the service's tobacco control policies and activities. Questions about support for smoke-free policies were also included in the TATS project survey of 2435 Aboriginal and Torres Strait Islander members of the communities served by the ACCHSs.

Main Outcome Measures: ACCHS tobacco control policies and activities.

Results: Thirty-two surveys were completed, covering 34 sites. Most ACCHSs (24/32) prioritised tobacco control “a great deal” or “a fair amount”, and all services had smoke-free workplace policies. Most had staff working on tobacco control and had provided tobacco control training within the past year. A range of quit-smoking information and activities had been provided for clients and the community, as well as extra smoking cessation support for staff. There was strong support for smoke-free ACCHSs from within the Aboriginal communities, with 87% of non-smokers, 85% of ex-smokers and 77% of daily smokers supporting a complete ban on smoking inside and around ACCHS buildings.

Conclusions: The high level of commitment and experience within ACCHSs provides a strong base to sustain further tobacco control measures to reduce the very high smoking prevalence in Aboriginal and Torres Strait Islander populations.

Citation

Nicholson, A.K., Borland, R., Sarin, J., Wallace, S., Van der Sterren, A.E., Stevens, M., Thomas, D.P. (2015). Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 202(10), S67-72.

Abstract

Objectives: To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit.

Design, Setting and Participants: A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013.

Main Outcome Measures: Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit.

Results: More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising.

Conclusions: Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.

Citation

Thomas, D.P., Bennet, P.T., Briggs, V., Couzos, S., Hunt, J.M., Panaretto, K.S., Stevens, M., Borland, R. (2015). Smoking cessation advice and non-pharmacological support in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. Medical Journal of Australia, 202(10), S73-77.

Abstract

Objectives: To describe recall among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers of having received advice to quit smoking and referral to nonpharmacological cessation support from health professionals, and their association with quit attempts.

Design, Setting and Participants: The Talking About The Smokes project used a quota sampling design to recruit 1721 smokers and exsmokers who had quit ≤ 12 months previously from communities served by 34 Aboriginal communitycontrolled health services and one community in the Torres Strait. Baseline surveys were conducted from April 2012 to October 2013. Results for daily smokers were compared with 1412 Australian daily smokers surveyed by the International Tobacco Control Policy Evaluation Project between 2006 and 2011.

Main Outcome Measures: Participants' recall of having been: seen by a health professional in the past year, asked if they smoke, advised to quit, and referred to other cessation support services; and having made a quit attempt in the past year.

Results: Compared with other Australian daily smokers, higher proportions of Aboriginal and Torres Strait Islander daily smokers saw a health professional in the past year (76% v 68.1%) and were advised to quit smoking (75% v 56.2% of those seen). Most Aboriginal and Torres Strait daily smokers who saw a health professional recalled being asked if they smoke (93%). Aboriginal and Torres Strait Islander daily smokers who had been advised to quit were more likely to have made a quit attempt in the past year than those who had not (odds ratio, 2.00; 95% CI, 1.58-2.52). Among all Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had been advised to quit, 49% were given a pamphlet or brochure on how to quit, but fewer were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%).

Conclusion: Most Aboriginal and Torres Strait Islander daily smokers recalled being recently advised by a health professional to quit, which was associated with making a quit attempt.

Citation

Thomas, D.P., Briggs, V., Couzos, S., Panaretto, K.S., Van der Sterren, A.E., Stevens, M., Borland, R. (2015). Use of nicotine replacement therapy and stop-smoking medicines in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. Medical Journal of Australia, 202(10), S78-84.

Abstract

Objective: To examine the use of nicotine replacement therapy (NRT) and the stop-smoking medicines (SSMs) varenicline and bupropion in a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers.

Design, Setting and Participants: The Talking About The Smokes (TATS) project used a quota sampling design to recruit a nationally representative sample of 1721 smokers and ex-smokers who had quit ≤ 12 months before from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline surveys were conducted from April 2012 to October 2013. These were compared with 1017 daily smokers from the general Australian population surveyed by the International Tobacco Control Policy Evaluation Project (ITC Project) from July 2010 to May 2011.

Main Outcome Measures: Past and intended use of NRT and SSMs, duration of use, and whether participants thought NRT and SSMs help smokers to quit.

Results: Compared with other daily Australian smokers, lower proportions of Aboriginal and Torres Strait Islander daily smokers had ever used any NRT or SSMs (TATS, 37% v ITC, 58.5%) or used them in the past year (TATS, 23% v ITC, 42.1%). Nicotine patches were most commonly used by Aboriginal and Torres Strait Islander smokers and recent ex-smokers (24%), followed by varenicline (11%) and nicotine gum (10%); most (74%) had got their last NRT at no cost. Among dependent Aboriginal and Torres Strait Islander daily smokers, those who were more socioeconomically advantaged were more likely than the disadvantaged to have used NRT or SSMs. Similar proportions of Aboriginal and Torres Strait Islander daily smokers and other Australian daily smokers said that NRT or SSMs help smokers to quit (TATS, 70% v ITC, 74.2%). Dependent Aboriginal and Torres Strait Islander smokers who had previously used NRT or SSMs were more likely to believe they help in quitting and to intend to use them in the future.

Conclusion: Aboriginal and Torres Strait Islander daily smokers, particularly those who are most disadvantaged, are less likely to have used NRT or SSMs than other Australian daily smokers. Some of the barriers to use, including cost, are being overcome, but further improvements are possible.

Citation

Thomas, D.P., Davey, M.E., Panaretto, K.S., Hunt, J.M., Stevens, M., Van der Sterren, A.E. (2015). Smoking among a national sample of Aboriginal and Torres Strait Islander health service staff. Medical Journal of Australia, 202(10), S85-89.

Abstract

Objective: To examine smoking among Aboriginal and Torres Strait Islander staff of Aboriginal community-controlled health services (ACCHSs).

Design, Setting and Participants: The Talking About The Smokes (TATS) project surveyed 374 Aboriginal and Torres Strait Islander staff at a national sample of 31 ACCHSs, from April 2012 to October 2013. We made comparisons with adult participants in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) and with 1643 smokers in a community sample of 2522 Aboriginal and Torres Strait Islander people also surveyed in the TATS project.

Main Outcome Measures: Smoking status, smoking behaviour at work, quitting behaviour, attitudes and beliefs about smoking and quitting.

Results: Aboriginal and Torres Strait Islander ACCHS staff had a lower smoking prevalence than among all Aboriginal and Torres Strait Islander adults surveyed in the NATSISS (38% v 49.8%), but this difference was smaller when compared with only employed adults (38% v 44.8%). Staff smokers had higher odds than smokers in their communities of ever trying to quit (odds ratio [OR], 2.1; 95% CI, 1.1- 3.7), of having often noticed anti-smoking advertising (OR, 2.8; 95% CI, 1.4-5.6), and of having used stop-smoking medications (OR, 3.0; 95% CI, 1.6-5.7), often with the support of their ACCHS. There was a significant association (P < 0.001) between the smoking status of Aboriginal and Torres Strait Islander staff and their confidence in talking to others about smoking and quitting; ex-smokers were most likely to report being confident. Most Aboriginal and Torres Strait Islander staff who smoked (74%) agreed that being a non-smoker sets a good example to patients at their health service, and most did not smoke with patients or at work where patients could see them.

Conclusion: Smoking prevalence among Aboriginal and Torres Strait Islander ACCHS staff is only modestly lower than among other employed Aboriginal and Torres Strait Islander people. Given that exsmokers feel more confident to help others quit than any other group, smoking cessation in ACCHS staff is a useful contributor to reducing community smoking rates.