Indigenous smoking: the need for a stronger response

Higher intensity interventions hold promise in tackling the problem of high indigenous smoking rates, according to a new meta-study published in the latest edition of the Australia and New Zealand School of Government’s Evidence Base journal.

The authors systematically reviewed 91 studies conducted on the cessation and prevention of smoking targeted towards Aboriginal populations in Australia, Canada, New Zealand and the United States. They found that intensive interventions with multiple, reinforcing components are useful:

“Based on the evidence produced we can confidently say that multi-faceted interventions that take into account various aspects of tobacco use at once such as biochemical addiction, habit, cultural reasons for smoking, and stressors and psychological reasons for smoking, are effective.”

An intensive, multi-pronged approach might include, for example, medication, culturally-tailored written resources, smoking bans at community events, counselling with a health worker, a community-wide program and an incentive scheme.

A characteristic identified with successful outcomes was the recruitment of individuals who are already highly motivated to quit. This means, however, that it can be difficult to generalise some outcomes observed to those not already considering giving up smoking.

Providing even two to three hours of training to health professionals in counselling smokers appears to be an effective means of stopping people from going back to cigarettes after quitting. For indigenous smokers, this effect is strengthened when the health worker is from an ATSI background.

Incentive schemes like “Quit and Win” competitions, such as one where Maori participants could win $5000 for a charity or community group, appear to help as well.

Research suggests culturally tailored program design is important, and that “an inappropriate match between program and participant characteristics may actually lead to an increase in the problem behaviour”.

Pharmacological interventions such as Champix, Zyban and nicotine patches were found to be useful when combined with “culturally tailored behavioural practice” and professional health support, though these medicines are not commonly prescribed to Aboriginal smokers currently.

Currently 16% of non-indigenous Australians smoke, compared to 42% of Aborigines and Torres Strait Islanders. In some remote communities, this rate is as high as 83%.

Although indigenous smoking rates have fallen in recent years, the gap between indigenous and non-indigenous Australians has remained relatively stable.

Up to 65% of indigenous women are reported to continue using tobacco when they fall pregnant, as a result of already high smoking rates and socio-economic disadvantage.

Of the very few programs targeted at pregnant indigenous women, there was no statistically significant evidence of successful intervention. A survey of patients and healthcare providers suggested “involving family” was the most effective strategy, while nicotine replacement therapies are seen by many experts as useful.

Indeed, perhaps the clearest finding is that there is a lack of high-quality evidence on many of the key questions about what works. There were few randomised and non-randomised controlled trials among the sample and many studies contained a small number of participants. Substantial attrition rates were common. Many known studies failed to publish all or any data.

For this reason, many of the studies in question showed “no evidence of any effect” — though this is of course not the same as being proven to be ineffective.

Programs without control groups mean it is impossible to conclude whether the specific intervention being tested made a difference, or if it was rather a national or state-wide change such as a health campaign, tax increase or similar change, that proved effective.

The use of electronic cigarettes in reducing smoking was highlighted as an area in need of further study. The authors also highlighted the need for more research into how to prevent people, especially youth, taking up smoking in the first place. The study concluded:

“In light of recent funding cuts from governments and a lack of reporting on existing heavily resourced interventions, the gap between Indigenous and non-Indigenous health will continue to remain a problem within our society for as long as we allow it to be one.”