Cessation Minimization Among Aboriginals: An Extensive Literature Review

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Discuss About The Cessation Minimization Among Aboriginals?

Australian indigenous people and aboriginals suffer from shorter life expectancies and higher burden of ill health conditions when compared to other nations. They have been suffering from worsened and poor health status since the 1970-1980s. The difference in the health situation between indigenous and non-indigenous groups is attributed to historical, socio-political and distal factors. Just like any other nation, the non- indigenous Australian population enjoys a better life expectancy. According to several studies, aboriginals who live in remote areas are vulnerable to a higher risk of smoking and poor healthcare facilities (Abs.gov.au, 2017).

Several studies that evaluate the ways by which aboriginal and indigenous smokers can be influenced and motivate to quit smoking have been conducted. Some studies have illustrated the different intervention strategies that should be followed to minimize or reduce the harmful effects of smoking or tobacco consumption on aboriginal health. This report aims to conduct an extensive literature review and summarize their findings on the effectiveness of interventions that can reduce harm related to tobacco consumption among indigenous Australian population.

Evidence based literature search to analyze the outcomes and effectiveness of several intervention services that have been implemented on indigenous Australian population for cessation of smoking habits and tobacco harm minimization was conducted. The main interest of this literature review lies in recognizing qualitative and quantitative research studies that gave an insight into the health outcomes and experiences of aboriginals. A multilevel iterative technique was designed for the literature search. 3 databases were used: MEDLINE (biomedical literature), CINAHL (allied health and nursing literature) and Cochrane library (randomized controlled trials and systematic review) (Bergamaschi et al. 2016). The abstracts of the retrieved articles were checked for relevance regarding intervention strategies. The search terms were “smoking prevalence in aboriginals”, “indigenous smoking harm reduction”, “smoking cessation among aboriginals”, “aboriginal tobacco control”. The inclusion and exclusion criteria were drawn.

• Any intervention that illustrated reduction of smoking or use of commercial tobacco was selected. The selected interventions were classified to key priority areas based on the working principles of NATSIHP. Studies were included in the review if they involved nonmedical therapeutic procedures.
• Peer reviewed journals published in English were used for the systematic review.
• Study literature not more than 5 years old were included in the review.
• The user group was indigenous adults who had smoking habits. The review focused on vulnerable, special and disadvantaged population group.

• Non-English journals and those published prior to 2012 were not considered.
• Interventions that illustrated reduction of ceremonial tobacco use were excluded.

Evidence from several data that focused on implementing smoke free policies suggested that exposure to second hand smoke and prevalence of smoking among young and adolescent significantly reduced on application of these policies. A study was conducted in the Cultural and Indigenous Research Centre that proved that stringent legislations related to smoking in public spaces has substantially reduced smoking environment over the past decade (Ell, Abel and Pedic 2013). It was suggested by Thomas, McLellan and Perera (2013) that effective media campaigns, smoking restriction in schools and promoting ill effects of smoking on the health of young people were effective in reducing the sales of tobacco among minors. When the retail outlets in the community adhere to the legislative regulations imposed by the government, the sales of tobacco could be effectively monitored. Another study showed that 3 business organizations out of 21, operating form the remote areas of Queensland northern communities practiced smoke free policies. The remaining 18 practiced informal smoking policies and all of these organizations had smoke free zones. However, these legislations often made the smokers feel persecuted. They also created a rift between the smokers and non-smokers and created a feeling of solidarity among them. The workforce should be consulted before implementation of any such smoke free policies to avoid untoward situations. This acted as a successful, intervention strategy (Campbell et al. 2014).

Inclusion criteria

An increase in the taxes imposed on tobacco successfully reduced the rate of tobacco purchase and motivated several people to quit smoking (Chaloupka, Yurekli and Fong 2012). Randomized control trials, pre and post studies were undertaken to monitor the effect of tobacco prevention and smoking cessation in indigenous people (Carson et al. 2014). It was found that smoking levels got considerably reduced in 12 out of 15 controlled trials on follow up. However, the results of cessation on the younger population were not evident. The study provided evidence for the combination of behavioral, psychological and biochemical factors to cater to the needs of indigenous population. Interventions that encompassed a greater number of components increased the likelihood of reducing smoking levels. Certain indigenous communities from Australia also proved that increase in the tobacco prices affected smoking rates. 7 months after there was an increase in tobacco price, the consumption rates among aboriginals were found to reduce by as much as 2.2% on an average (Thomas et al. 2012). However, the results were not consistent across all the stores that were analyzed for the study.

Mass media campaigns and social marketing strategies have an important role to play in smoking cessation and act as good intervention policies. The campaigns have proved effective in preventing smoking when they were combined with tobacco control measures (Durkin, Brennan and Wakefield 2012). These campaigns help in molding and altering the behavior and attitude of smokers towards tobacco consumption and promote the benefits of abstinence from smoking. They help in preventing smoking relapse among aboriginals by reminding them the reason behind stopping smoking (Wakefield et al. 2012). Television has been proved to the most efficient mode of media strategy that has a wider reach among people belonging to all strata of population and positively influences adult smokers. Moreover, personal testimonials are also essential in positively influencing people to quit smoking (Farrelly et al. 2012).

A study that reviewed the effect of smoking among indigenous population by using several randomized control trials failed to show any significant effects of smoking cessation on both aboriginal or non-aboriginal Australian population. Higher rates of smoking cessation were reported among people who were subjected to intervention methods. Cultural approach and knowledge based awareness drives helped to increase quitting rates (Gould et al. 2012). A national survey, ‘Talking About the Smokes’, displayed the voice of 3000 indigenous smokers and non-smokers (Thomas 2014). The survey suggested that future activities, which target smoking cessation among aboriginals, should utilize the standards of society acceptance for tobacco consumptions. An intensive program designed for aboriginal population showed significant reduction rates in smoking quit rates by double amount (Marley et al. 2014).

Exclusion criteria

A school based disease education program was also conducted that influenced healthy lifestyle choices among indigenous people and encouraged positive role model influences on the students. This study was conducted across 20 schools and utilized video campaigns and social marketing strategies. It proved to have a positive impact on the attitude, knowledge and self efficacy of the aboriginal students and reduced the impact of smoking among them (Malseed et al. 2014). The quit rates increased to a significant amount of 12% on application of intensive counseling therapies. However, disparity between the number of participants adhering to usual care routines (95) and those using the intervention (49) made the study statistically underpowered. 11 different approaches that were based on increasing rates of physical activity among young aboriginals were identified in one study. Out of these approaches, implementation that targeted the community showed significant and relevant positive effects in smoking cessation on a follow up after 12 months (Baker and Costello 2014).

A critical appraisal was undertaken to determine the effectiveness and evidence quality of each intervention strategy. These CASP tools will help to formulate and design future recommendations and sustainability of the proposed intervention techniques (Munn et al. 2014).

	Chamberlain et al. 2017	Roche and Ober 1997
Did the review address a clearly focused question?	Yes (investigated evidence for tobacco consumption reduction among indigenous people)	Yes (examined the potential of harm minimization to address smoking among aboriginals and Torres Strait islanders)
Did the authors look for the right type of papers?	Yes (MEDLINE, EMBASE and indigenous health databases were searched)	Can’t tell (No information on the search strategy or use of any database is available)
Were all relevant studies included?	Yes (21 studies that focused on effective interventions for smoking reduction among aboriginals were included)	Yes (most of the studies that were assessed focused on smoking among aboriginal health workers, tobacco use in Australia, household and national surveys and mortality among indigenous people. However, some articles on heart diseases, territory health outcome, psychoactive harm reduction and drug addiction were also considered)
Did the author do enough to access the quality of included studies?	Yes (the studies not only included indigenous participants from Australia but also focused on other vulnerable and disadvantaged population)	Yes (they analyzed several surveys to identify the essential elements related to tobacco reduction and devised approaches for harm minimization)
If the results have been combined, was it reasonable to do so?	Yes, the results were combined since, thorough analysis of data from all the included studies provided access to a variety of evidence based smoking cessation practices and suggested the role of mass media campaigns in harm minimization.	Yes, most of the studies focused on decreasing mortality and morbidity, increasing cessation, reducing healthcare expenditure and second hand exposure to smoke.
What are the overall results?	4studies reported that a surge in tobacco taxes and price reduces their affordability and prompts quitting of smoking. 3 studies identified the effectiveness of implementation of legislative interventions and pack warnings in reducing tobacco sales among minors. Majority of the studies illustrated that mass media campaigns, social marketing, community based strategies subsequently change the behavior and perception among tobacco consumers and promote tobacco cessation when they are applied in conjunction with other control activities.  Pharmacological interventions like use of bupropion and nicotine replacement therapies also work as efficient interventions. The studies also suggested the presence of smoke free environment to reduce second hand smoke exposure among people.	The study showed that major harm reduction strategies should include increasing accessibility to treatment, decreasing drug intake, safer delivery routes, early detection monitoring, protecting non-smokers by restricting smoking zones and destigmatising use by showing  empathy towards aboriginals who failed to quit smoking.
How precise are the results?	The review was examined for similarities with the principles of NATSIHP. The major priorities were well identified in most of the primary studies. However, some of the secondary studies failed to provide evidence for fine aspects of the probable interventions.	The indigenous community practiced fewer harm reduction or cessation approaches than the wider communities. The study evaluated the National Drug Strategy Survey, which showed that 32 aboriginals had reduced smoking in 1994, compared to 41 people belonging to the general population in 1993.
Can the results be applied to local population?	Yes	Yes
Were all important outcomes considered?	Yes (Effect of elimination of smoking promotion or advertising were not identified in any indigenous population specific study)	No (effect of media campaigns, taxation rates and smoking legislations were not measured)
Are the benefits worth the harm and costs?	Yes (There were no harms associated)	Yes (harm reduction concept needs to be destigmatised among aboriginals)

	Malseed et al. 2014	Marley et al. 2014	Carson et al 2014
Did the trial address a clearly focused issue?	Yes (investigated the effectiveness of health programs in schools for aboriginals to combat chronic health conditions)	Yes (tested efficacy of multidimensional smoking cessation program on aboriginals)	Yes (evaluated the effectiveness and safety of VT and quitline on smokers)
Was the assignment of patients to treatment randomized?	No	Yes	Yes
Were all patients accounted for at conclusion?	Yes	Yes (study endpoints were considered at 6 and 12 months after enrolment)	Yes (12 weeks of treatment was followed for all participants)
Were patients, health workers and study personnel blind to treatment?	No	The staff were blinded to the study	Yes
Were the groups similar at start of trial?	Yes (11-18 years of students were selected)	Yes (aboriginal and Torres Strait islanders, aged more than16 years were selected)	Yes (all patients were adults with smoking related diseases)
Were the groups treated equally?	Yes (Deadly choice program was applied to all)	Yes (all participants received routine care related to smoking cessation	Yes (subjects received varenicline tartrate and quitline counseling together)
How large was the treatment effect?	Significant changes observed in intervention group regarding knowledge on smoking	Smoking cessation rate was double for intervention group	VT was tolerated among subjects with acute smoking illness; self reported adverse event was nausea
How precise was the estimate of treatment effect?	(P= 0.006)	(P= 0.131)	(16.3% nausea in the VT+C group and 1.5% in the counseling group)
Can the results be applied in this context?	Yes	Yes	Yes
Were all clinically important outcomes considered?	Yes (physical activity, leadership education and health checkup increases self efficacy among minors and can promote smoke quitting).	Yes (Self reported smoking cessation rates were measured at final follow up)	Yes (effect of VT+quitline counseling and of quitline counseling alone were  measured)

Tobacco use has a substantially greater prevalence among Aboriginal and Torres Strait Islanders when compared to the general Australian population. 42% of the indigenous population is daily smokers and the smoking rates among them are considerably high (Upton et al. 2014). However, national surveys suggest that a progressive decline in daily smoking limits have been observed since the last decade. Several socio-economic factors, psychological stress, homelessness and exposure to criminal system act as major contributors to high smoking prevalence among aboriginals. Several randomized control trials and systemic reviews provide evidence for the effectiveness of intervention methods on smoking cessation activities. From the above discussed literature review it can be concluded that smoking cessation interventions include motivational counseling,  peer support programs, pharmacotherapy, increased educational awareness in ill effects of tobacco consumption, social and mass media campaigns, tobacco litigation and proper enactment of the legislations at all places, creating smoke free environments and increasing tax rates on tobacco products.

These intervention programs must be funded because they will help to curb down healthcare costs significantly (they reduced costs associated with hospitalizations by $ 134 billion in California), will increase productivity at workplace and lead to less occurrence of disabilities (Lightwood and Glantz 2013). Moreover, if these interventions are funded then they will reduce medical expenditures and incidence of smoking related chronic diseases. Previously conducted cessation programs have proved beneficial in reducing the number of adult smokers and have shown a drastic fall in cigarette sales (Rabius et al. 2014). Therefore, it can be concluded that if the government agencies and health based organizations increase their funding on research and development of smoking cessation programs, the aboriginals would be highly affected and a healthy community will prevail.

Intervention strategies

References

Abs.gov.au (2017). 4714.0 – National Aboriginal and Torres Strait Islander Social Survey, 2014-15. [online] Abs.gov.au. Available at: https://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4714.02014-15?OpenDocument [Accessed 23 Sep. 2017].

Baker, P. and Costello, J., 2014. Evidence Synthesis on Effective Physical Activity and Nutritional Health Promotion Programs.

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Campbell, S., Bohanna, I., McKeown-Young, D., Esterman, A., Cadet-James, Y. and McDermott, R., 2014. Evaluation of a community-based tobacco control intervention in five remote north Queensland Indigenous communities. International Journal of Health Promotion and Education, 52(2), pp.78-89.

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