Australia Aboriginal Strait Islander Health: Smoking And Harm Reduction Interventions

Negative Effects of Smoking

Discuss About The Australia Aboriginal Strait Islander Health?

People of Aboriginal and Torres Strait Islander population are more susceptible to smoking addiction development as compared to the non-indigenous communities. It is evident that smoking has multiple negative effects on the health of these people. Nature of smoking can be adaptive and addictive. Social, economic and structural factors are responsible for the more prevalence of smoking in this population. It has been observed that more prevalence of smoking in this population is mainly due to the insufficient training for smoking cessation. Aboriginal health workers who smoke cannot provide training because of their cognitive decline. Due to smoking, there is higher incidence of stroke, heart disease, diabetes and circulatory disease in aboriginal population (Vos et al., 2009). Less attention to the smoking cessation programmes may be due to less visible impacts of smoking as compared to the alcohol consumption. Negative impacts of smoking can be evident only after diagnosis of certain disease. Hence, there is less awareness of potential detrimental effects of smoking among aboriginal origin people. In the surveys, it is evident that less than 5 % aboriginal people knows that smoking can negatively affect their health. As a result, very less efforts were made for reducing smoking in this population. For aboriginal people, cultural dominance is also one of the important factor responsible for the smoking prevalence. Supply of tobacco along with regular ratio, was one the major factor responsible for the prevention of smoking in the aboriginal population. Consumption of Tabaco was carried forward form the complex historical antecedents to current-day tobacco users in this population (Robinson et al., 2010).

Poverty in aboriginal people is also considered as one of the factor for augmented smoking in aboriginal people. These people try to present their life as luxury life and social acceptance through smoking. Because of these complex causes and sustained increase in the smoking, it would be challenging to control smoking in this population. Until recently, most the prevention methods of smoking are traditional methods. However, in recent past newer methods like harm reduction are implemented. Harm reduction strategy involves efforts to reduce adverse effects and social and economic consequences of smoking without reducing consumption of smoking. In this harm reduction approach, there would be acceptance of tobacco use of person and maintenance of dignity of the person. Harm reduction in smoking can be achieved by reducing recruitment, increasing cessation, reducing risks of active and passive smoking. Integration of harm reduction approaches and cessation approaches proved beneficial in individual and public status of aboriginal people. However, most of the aboriginal people feel smoking cessation is a difficult task for them because these people can’t offered to spend time and energy in smoking cessation intervention (MRoche & Ober, 1997).

Factors Responsible for Smoking Prevalence

Literature search was carried out by using different databases like Embase, Ovid MEDLINE, PsychINFO and CINAHL. Literature search is divided into three categories. These categories include indigenous people, tobacco or smoking use and intervention. Ingenious people search strategy include aboriginal people, native Australians and Torres Strait Islander. Tobacco search strategy include tobacco, smoke, smoking, cigar, tobacco use and cigarettes. Intervention search strategy include smoking intervention, smoking reduction, tobacco control, smoking cessation, tobacco reduction, smoking restriction, tobacco reduction strategy, quit smoking and tobacco control strategy. These search items were searched individually and in combination based on the database. Different criteria were used for the selection of articles. First, article should be published. Second, intervention should be carried out on Aboriginal Australian people. Articles were selected comprising of research designs like interventions, case control, cohort, cross-sectional, experimental, and intervention designs. Articles between 1996 to 2016, were selected. All these databases yielded 1714 articles and after removal of duplicates 1345 articles were obtained. In the final step, 31 eligible articles were selected relevant to the essay.

Critical appraisal of the research article should be carried out under different aspects like title and abstract, structuring of the study, sample selection, data collection, data analysis, findings and conclusion. Aims, objectives and hypothesis should be clearly mentioned in the research article. Data collection method should be clearly explained and expertise of the data collection person should incorporated. Ethical issues in the data collection should clearly mentioned. Reliability and validity of the data collection instruments and methods should be adequately described. In data analysis name of the statistical methods like primarily descriptive, correlational or inferential should be mentioned. Whether results are clinically or statistically significant should be clearly mentioned. Whether is study is blinded should be clearly mentioned to eliminate question of bias. Outcome of each statistical analysis should be identified and meaning of each outcome should be explained. Results should be clearly and completely stated and enough information should be provided to judge the results. Researcher should provide summary of the obtained results and made suggestions for the future studies. Limitations and implications of the study should be clearly mentioned. Enough information should be provided in the study to replicate the study. Discussion should be provided in the article comprising of participants values, clinical expertise and available evidence (Kmet et al., 2004; Smylie et al., 2016).

Different types of research are available for the smoking cessation. These include randomised controlled trials, controlled clinical trials, pre-post studies and government reports.  Methodological problems in the form of study design were observed in few of the studies. In few of the pre-post studies and government reports, there is no mention of either randomised or non-randomised controlled study. Data for the comparator population is not mentioned in none of the government reports (Australian Bureau of Statistics, 2013; 2014b). Data related to subject recruitment is clear in most of the studies. Most of the studies are not meeting the criteria for the mentioned number of subject population. Less number of subjects are incorporated in the studies as compared to the mentioned number. Available studies are with less population, hence generalisability of the data is difficult. There is more attrition rate in the number of subjects in the follow-up studies. Moreover, reason behind the attrition rate was not mentioned. As a result, generalisability and comprehensiveness of the follow-up studies is questionable. Data related to characteristic of population those who participated in the follow-up and those who didn’t participated in the follow-up is missing form these studies (Marley et al., 2014; Passey et al., 2009).

Harm Reduction Strategy

Different factor like socio-economic status and cultural aspects can affect the outcome in the smoking cessation studies. However, in few studies these aspects were not categorised in the analysis of results. Categorisation of results based on these aspects would have given more clarity of the smoking cessation interventions. There could be different outcomes in the smoking cessation studies like continuous smoking self-denial, point prevalence and complete acceptance of the intervention. However, in few of the studies, results were not categorised according these categories (Cosh et al., 2015; Gould et al., 2013). Data collected in these studies by different stakeholders like Indigenous health workers, research assistants and doctors. However, expertise and experience of these stakeholders in the smoking cessation is not mentioned in these articles. Research and survey data collected by the experts should be considered as the valid data. Hence, collected data in few these studies is questionable. In these studies, data is collected by face-to-face interaction, self-reports and online assessment. Data collection methods like self-reports and online assessment are prone to bias. Self-reports can be collected in the presence of health or social worker to improve validity of the data (Tooth et al., 2005).

There is flaw in the statistical analysis in few of the studies. There is huge difference between statistical significance and clinical significance. However, statistical significance is the most important requirement for the validity of the data. Statistical significance is not possible in the studies without comparator and in studies with insufficient power to detect the effect. In most of the studies, mentioned conclusion is not comprehensive and it reflects only some part of the study. Few of the studies specifically mentioned category of subject population. This information would be helpful in the assessment of smoking intervention population. Quality of research can be assessed based on the clarity of the category of subject population. 17 studies were specifically carried out on the adults and 14 studies were carried out on both adults and young. Studies should also mention specific aims and objectives of the research. It would be helpful in the assessing understanding of the researcher about the research area. Approximately 12 studies studied both prevention and cessation intervention programmes, 17 studies studied just cessation and only two studies studied tobacco prevention. Locality or geographic location of the subject population is important aspect in studies like smoking cessation because smoking cessation can be affected by different factors like cultural and socio-economic factors. These studies were carried out in different regions like Northern Territory, Queensland, New South Wales, Australian Capital Territory, Victoria, Tasmania,  South Australia and Western Australia. However, none of the studies were carried out based on the comparison among different regions. Comparative studies among different regions would have given more generalisation of the research design and methods used in these studies. Interventions used in these methods were in the form of media education, counselling, incorporation of social or healthcare workers and pharmacotherapy. Very less studies were performed with combination of these interventions (Gould et al., 2013; Nicholson et al., 2015).    

Literature Search

Study conducted by Mckennitt and Currie, 2012; didn’t allowed direct comparison between intervention group and control due to small sample size. Another study conducted by Glover et al. 2009, also produced confounding results due to small sample size. In this study, results were obtained in the favour of control group. Campbell et al. 2014 conducted a controlled clinical trial in 702 Aboriginal and TSI Australian people above 15 years of age. In this study, motivational counselling was provided by the trained healthcare professionals. This study conducted in both rural and urban areas with incorporation of sufficient number participants. Hence, in this study statistically results were obtained and these results can be generalised to overall population. If recruited participants would have been equally distributed among rural and urban populations, more evident results in the form of effect of different classes of people on smoking cessation, would have been obtained. Marley et al. 2014, conducted randomised clinical trial in 168 Aboriginal Australian people above age of 16. In this study, interventions like motivational interview and pharmacotherapy were used together. However, main drawback of this study was its less number of participants. Hence, in this study clinical difference was obtained among control group and intervention group. However, there was no statistical difference between these two groups. Hearn et al. 2011; conducted pre post study in Aboriginal Australian people. In this study, smoking cessation training was provided. Even though study population was less in this study, statistically significant difference between control group and intervention group was observed. These results might be obtained because intervention was carried out by expert professionals in in Aboriginal health and education.

Conclusion:

 It has been observed that reductions in the smoking are evident in the Aboriginal people of Australia, however these are coming at very low speed. It is evident form the literature that studies comprising of integrated interventions targeted towards biochemical, habit forming, cultural, stress related and psychological aspects, proved beneficial in the smoking cessation. These interventions proved more beneficial in the people those are already motivated for smoking cessation. Hence, these interventions should be considered as support mechanism rather than tool. Research design and clinical practice efforts should be directed towards making transition of these interventions from support mechanisms to tool for smoking cessation. In studies, it has been established that pharmacotherapy is successfully implemented in smoking cessation. Studies comprising of pharmacotherapy, produced statistically and clinically significant results in the smoking cessation. However, pharmacotherapy was underused in Aboriginal Australian people. Other intervention techniques like training to healthcare professionals for smoking cessation, motivational interview techniques, behavioural support and interventions considering cultural aspects, traditions and languages proved beneficial in smoking cessation. From the literature, it is evident that identifying unsuccessful intervention is difficult task. Hence, more efforts should be made to identify unsuccessful intervention. Effective evaluation procedures should be implemented for smoking cessation programmes. Integrated efforts of health workers, social workers and government agencies would be helpful in implementing effective smoking cessation programme in Aboriginal Australian population.

Critical Appraisal

References:

Australian Bureau of Statistics. (2013). Profiles of Health, Australia, 2011-13 Canberra: Australian Bureau of Statistics, viewed 18 September 2017 <www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4338.0~201113~Main%20Features~Tobacco%20smoking~10008>. Australian Bureau of Statistics 2014a. 4727.0.55.001.

Australian Bureau of Statistics. (2014b). Australian Aboriginal and Torres Strait Islander Health Survey: Updated Results, 2012–13, Canberra: Australian Bureau of Statistics, viewed 18 September 2017, <www.abs.gov.au/AUSSTATS/[email protected]/mf/4727.0.55.006>.

Cosh, S., Hawkins, K., Skaczkowski, G., Copley, D., & Bowden, J. (2015). Tobacco use among urban Aboriginal Australian young people: a qualitative study of reasons for smoking, barriers to cessation and motivators for smoking cessation, Australian Journal of Primary Health. 21(3), pp. 334-41.

DiGiacomo, M., Davidson, P.M., Davison, J., Moore, L., & Abbott, P. (2007). Stressful life events, resources, and access: key considerations in quitting smoking at an Aboriginal Medical Service. Australian and New Zealand Journal of Public Health. 31(2), pp. 174-176.

Eades, S.J., Sanson-Fisher, R.W., Wenitong, M., Panaretto, K., D’Este, C., Gilligan, C., & Stewart, J. (2012). An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial. Medical Journal of Australia. 197(1), pp. 42-46. 

Gould, G.S., McGechan, A., and van der Zwan, R. (2009). Give up the smokes: a smoking cessation program for Indigenous Australians, 10th National Rural Health Conference, viewed 18 September 2017, www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/papers/docs/Gould_Gillian_D9.pdf.

Gould, G.S., Munn, J., Watters, T., McEwen, A., & Clough, A.R. (2012). Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders: A systematic review and meta-ethnography. Nicotine & Tobacco Research. 15(5), pp. 863-74.

Gould, G.S., Munn, J., Avuri, S., Hoff, S., Cadet-James, Y., McEwen, A., & Clough, A.R. (2013). Nobody smokes in the house if there’s a new baby in it”: Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia, Women and Birth. A journal of the Australian College of Midwives. 26(4), pp. 246-253. 

Hearn, S., Nancarrow, H., Rose, M., Massi, L., Wise, M., Conigrave, K., Barnes, I., &  Bauman, A. (2011). Evaluating NSW SmokeCheck: a culturally specific smoking cessation training program for health professionals working in Aboriginal health. Health Promotion Journal of Australia.  22(3), pp. 189-198. 

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Marley, J., Atkinson, D., Kitaura, T., Nelson, C., Gray, D., Metcalf, S., & Maguire, G.P. (2014). The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting. BMC Public Health. 14, pp. 32-41.

McKennitt, D.W., & Currie, C.L. (2012). Does a culturally sensitive smoking prevention program reduce smoking intentions among Aboriginal children? A pilot study. American Indian and Alaska Native Mental Health Research. 19(2), pp. 55-63.

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

Passey, M., Gale, J., Holt, B., Leatherday, C., Roberts, C., Kay, D., Rogers, L., & Paden, V. (2009).  Stop smoking in its tracks: understanding smoking by rural Aboriginal women, Paper presented at the 10th National Rural Health Conference, Cairns, Australia, viewed  18 September 2017, <www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf>.

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