Australian Health Promotion Association

Shane Hearn, Hannah Nancarrow, Miranda Rose, Luciana Massi, Marilyn Wise, Katherine Conigrave, Ian Barnes and Adrian Bauman

Introduction:  Tobacco smoking is the greatest single contributor to overall mortality and the burden of disease among Aboriginal populations. Tobacco smoking not only causes early death; it also greatly diminishes quality of life.1 The importance of reducing these two impacts is demonstrated through the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes where Australia’s leading Indigenous and non-Indigenous health peak bodies and human rights organisations have joined forces to close the life expectancy gap within a generation.2

In 2004-05 half (50%) of the adult Indigenous (Aboriginal and Torres Strait Islander) population of Australia were current smokers. While smoking has decreased in the Australian population due to comprehensive tobacco control strategies, this change has not been reflected in Aboriginal communities.3 In NSW, Aboriginal smoking rates are threefold higher than the state average, with 43.2% of Aboriginal adults in NSW reporting current smoking.4 In Australia, population groups where the prevalence of smoking continues to be high include the Aboriginal population, people with a mental illness or substance misuse disorders and prisoners. These groups share some common characteristics including limited educational attainment, higher rates of unemployment, social isolation, interpersonal conflict and financial insecurity.5,6 There is strong evidence of the positive association between these social determinants and high rates of sustained smoking.7

Despite the importance of tobacco smoking as a cause of premature death and ill health in Aboriginal communities it has received limited attention in the past. In a review of tobacco programs for Indigenous people, only four published evaluations of tobacco interventions were identified, none of which measured smoking cessation rates.8 More recent intervention studies show the benefits of providing tailored programs to Aboriginal clients but have not published data demonstrating a decrease in personal tobacco consumption.9,10 However, there is evidence that interventions that provide group work, one-on-one counselling and include some form of subsidised nicotine replacement therapy (NRT) do prompt quit attempts among patients.9,11,12 Several studies identify the importance of the social and cultural contexts within which tobacco smoking occurs, and note that tobacco control programs should acknowledge the social exchange that occurs when smoking, the role of family and the high rates of stress experienced by Aboriginal people.9,12,13

The high proportion of the Aboriginal population in contact with the health system each year means there are significant opportunities for health professionals to provide support and brief advice on smoking and making a quit attempt.14,15 There is evidence that smokers are more likely to consider changing their behaviour after receiving advice from health workers during their contact with a health service.14,15 In 2003 the World Health Organization published evidence-based recommendations on the treatment of tobacco dependence, including that all health professionals should be trained to advise and support smokers to stop smoking.16

Furthermore, smoking cessation interventions, especially brief interventions, are effective approaches to reducing smoking-related health care costs.17 There is good evidence substantiating the effectiveness of training health workers to deliver smoking cessation brief interventions in other populations suggesting that training might also be effective for Aboriginal Health Workers (AHWs) and other health professionals working with Aboriginal clients.8

AHWs have pivotal roles in health services. Their professional knowledge, skills and experience combined with their cultural understanding make AHWs essential to the success of all initiatives promoting the health of Aboriginal families and communities. However, AHWs themselves identify that a lack of training is a major barrier to being able to offer smoking cessation advice and support to clients.12,18

This paper describes the evaluation of a culturally specific training program for AHWs and other health professionals to strengthen their capacity to deliver an evidence-based brief smoking cessation intervention to their Aboriginal clients who smoke. The training was designed with the cultural needs of the Aboriginal smoker-client and the Aboriginal clinician in mind. The impact evaluation assessed whether participation in the training program increases confidence, knowledge and skills in providing smoking cessation advice and support to Aboriginal clients.

SmokeCheck training was based on several existing programs – Smokescreen,19 the Queensland SmokeCheck Project,20 the Smoking Cessation Guidelines for Australian General Practice,21 and the NSW Health Let’s take a moment quit smoking brief intervention − a guide for all health practitioners.22 Although each of these interventions differ, they share some similarities including the use of the Stages of Change model to assess individual client’s readiness to quit and the 5As approach which requires practitioners to ask, assess, advise, assist and arrange follow up for clients who smoke.19-22 The most significant difference is in SmokeCheck, which was the first quit smoking brief intervention designed for and piloted with Indigenous people in North Queensland. The program includes culturally appropriate resources to assist health professionals to deliver the intervention with Indigenous clients.

The NSW SmokeCheck Program modified these approaches, produced resources and pilot-tested them in Aboriginal communities in NSW. Subsequently, the NSW Department of Health and the Cancer Institute NSW funded this large-scale intervention project, the NSW SmokeCheck Program. The training program consisted of a one-day workshop for health workers in the delivery of the SmokeCheck smoking cessation brief intervention with Aboriginal clients. The workshop covered topics designed to maximise understanding of the impact of smoking on Aboriginal communities including: the history of tobacco use, national and state Indigenous smoking data, the social determinants and health effects of smoking, how to conduct a brief intervention using the SmokeCheck resources, and how to advise clients who smoke about effective ways to quit. The training format comprised face-to-face interactive presentations, group work and case studies, and participants were encouraged to ask questions and share personal experiences. To further ensure the training’s cultural relevance all presentations were undertaken jointly by an Aboriginal and non-Aboriginal presenter, both with experience in Aboriginal health and education. In addition, the Project’s Chief Investigator who is also Aboriginal, provided input.

Ethics clearance was granted for SmokeCheck from the Aboriginal Health and Medical Research Council and the University of Sydney. It was governed by a steering committee comprised of the NSW Department of Health, Cancer Institute NSW, an Area Director and Manager of Aboriginal Health, and the Project’s Chief Investigator. In collaboration with expert advisers in evaluation, tobacco control and health promotion, the Project Team delivered the SmokeCheck training program across New South Wales over 15 months in 2007 and 2008.

Issue addressed: This paper reports on the evaluation of a culturally specific smoking cessation training program (SmokeCheck) for health professionals working in Aboriginal health in NSW. Training aimed to increase professionals’ knowledge, skills and confidence to offer an evidence-based quit smoking brief intervention to Aboriginal clients.
Methods: Using a quasi-experimental pre-post with 165 matched intervention participants, surveys were completed immediately before (baseline) and 6-months post training. The control group were on a waiting list for 6 months before receiving the intervention, and completed surveys at baseline, immediately before training and 3-6 months following training. Surveys assessed knowledge, skills and confidence to deliver the intervention, availability of resources, and smoke-free status of homes.
Results: Post training, a higher proportion of intervention group participants were more confident talking about health effects (22%, p=0.001), offering quit advice (27%, p=0.001), assessing readiness to quit (31%, p=0.001) and initiating a conversation about smoking (24%, p=0.001). After training, more participants reported providing advice about NRT (15%, p=0.001), ETS (12%, p=0.006), and reducing tobacco use (10%, p=0.034), but no changes were reported in smoking or intention to quit. Conversely, the control group showed no significant changes.
Conclusions: SmokeCheck training strengthened participants’ knowledge, skills and confidence to deliver a smoking cessation intervention to Aboriginal clients. ‘
So what? Building the capacity of health professionals to deliver a culturally specific smoking cessation intervention potentially improves opportunities for Aboriginal clients to make a quit attempt.

Health Promotion Journal of Australia 2011; 22: 189-95