Exploring the reporting, intake, and recommendations of primary food sources of whole grains globally: a scoping review.

Whole-grain intake is associated with reduced risk of non-communicable diseases (NCDs). Greater understanding of major food sources of whole grains globally, and how intake has been quantified, is essential to informing accurate strategies aiming to increase consumption and reduce NCD risk. Therefore, the aim of this review was to identify the primary food sources of whole-grain intake globally and explore how they are quantified and reported within literature, and their recommendation within respective national dietary guidelines. A structured scoping review of published articles and grey literature used a predefined search strategy across electronic databases. Data was extracted and summarised based on identified outcomes (e.g., primary sources of whole-grain intake, quantification methods). Dietary intake values were noted where available. Thirteen records across 24 countries identified bread and bread rolls, and ready-to-eat cereals as primary sources of whole-grain intake in Australia, New Zealand, Europe, the United Kingdom, and Northern America. Elsewhere, sources vary and for large parts of the world (for example Africa and Asia), intake data is limited or non-existent. Quantification of whole grain also varied across countries, with some applying different whole-grain food definitions, resulting in a whole-grain intake based on only consumption of select "whole-grain" foods. National dietary guidelines were consistent in promoting whole grain intake and providing examples of country specific whole-grain foods. Consistency in whole-grain calculation methods is needed to support accurate and comparative research informing current intake evidence and promotional efforts. National dietary guidelines are consistent in promoting whole-grain intake, however there is variability in recommendations.

Food Compass 2.0 is an improved nutrient profiling system to characterize healthfulness of foods and beverages.

Food Compass is a nutrient profiling system used to assess the healthfulness of diverse foods, beverages and meals. Here we present a revised version of Food Compass (Food Compass 2.0) incorporating new data on specific ingredients and the latest diet-health evidence. Food Compass 2.0 has been validated against health outcomes in a population from the United States and demonstrates enhanced ability to characterize foods and beverages based on their healthfulness.

Selective industry adoption of a voluntary front-of-pack nutrition label results in low and skewed uptake: 10-year results for the Health Star Rating.

Front-of-pack nutrition labelling (FOPNL) on packaged foods is recommended by the World Health Organization to promote healthier diets. Our aim was to assess uptake of Australia's FOPNL, the Health Star Rating (HSR), overall and by HSR score received (0.5 (less healthy) to 5.0 (more healthy) in 0.5 increments) after ten years of voluntary implementation. In a sample of 21,197 products, we found HSR uptake of 37% overall in 2023. Uptake was unevenly distributed, with 24% of products with an HSR ≤ 3 displaying the label, compared to 53% of products scoring ≥3.5 (p < 0.001). Low HSR uptake on poorly rated products demonstrates that most food manufacturers will only display FOPNL where marketing value exists in a voluntary system. Poor and uneven HSR uptake limits consumers' ability to meaningfully use the label to compare and choose healthier products. Government action is urgently required to make the HSR system mandatory.

Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing.

AIM: To modify the Australian and New Zealand Health Star Rating to account for ultra-processing and compare the alignment of the modified ratings with NOVA classifications and the current Australian Dietary Guidelines classifications of core (recommended foods) and discretionary (foods to limit). METHODS: Data was cross-sectionally analysed for 25 486 products. Four approaches were compared to the original Health Star Rating: (1) five 'negative' points added to ultra-processed products (modification 1; inclusion approach); (2) ultra-processed products restricted to a maximum of 3.0 Health Stars (modification 2; capping approach); (3 and 4) same approach used for modifications 1 and 2 but only applied to products that already exceeded 10 'negative' points from existing Health Star Rating attributes (modifications 3 and 4, respectively; hybrid approaches). Alignment occurred when products (i) received <3.5 Health Stars and were NOVA group 4 (for NOVA comparison) or discretionary (for Dietary Guidelines comparison), or (ii) received ≥3.5 Health Stars and were NOVA groups 1-3 or core. RESULTS: All Health Star Rating modifications resulted in greater alignment with NOVA (ranging from 69% to 88%) compared to the original Health Star Rating (66%). None of the modifications resulted in greater alignment to the Dietary Guidelines classifications overall (69% to 76%, compared with 77% for the original Health Star Rating), but alignment varied considerably by food category. CONCLUSIONS: If ultra-processing were incorporated into the Australian and New Zealand Health Star Rating, consideration of ultra-processing within the broader dietary guidance framework would be essential to ensure coherent dietary messaging to Australians.

Switches in food and beverage product purchases can reduce greenhouse gas emissions in Australia.

Switching between similar food and beverage products may reduce greenhouse gas emissions (GHGe). Here, using consumer data linked to 23,550 product-specific GHGe values, we estimated annual GHGe attributable to product purchases consumed at home in Australia and calculated reductions from specific switches. Potential changes to mean Health Star Rating, mean energy density and the proportion of ultraprocessed foods purchased were assessed. Approximately 31 million tonnes of GHGe were attributable to products consumed at home in 2019, the three highest contributors of GHGe being 'meat and meat products' (49%), 'dairy' (17%) and 'non-alcoholic beverages' (16%). Switching higher-emission products for 'very similar' lower-emission products could reduce total emissions by 26%. Switches to 'less similar' lower-emission products could lead to a 71% reduction. Switches had little impact on the average Health Star Rating, energy density of purchases and proportion of ultraprocessed foods purchased. Directing manufacturing and marketing towards lower-environmental-impact products and signposting such options to consumers are key.

Extent of alignment between the Australian Dietary Guidelines and the NOVA classification system across the Australian packaged food supply.

AIMS: The Australian Dietary Guidelines are currently being revised and ultra-processed foods have been identified as a high priority action area. To better understand how well the current Dietary Guidelines align with level of processing classifications, the aim of this study was to assess the alignment between the Australian Dietary Guidelines and the NOVA classification system for classifying the healthiness of packaged foods. METHODS: Data were sourced from the Australian FoodSwitch dataset, which included 28 071 packaged food and beverage products available in major Australian supermarkets in 2022. Products were classified as (i) core or discretionary (Australian Dietary Guidelines) and (ii) non-ultra-processed or ultra-processed (NOVA). Agreement between the two systems (core vs. non-ultra-processed and discretionary vs. ultra-processed) was evaluated using the kappa statistic. RESULTS: There was 'moderate' agreement (κ = 0.41, 95% CI: 0.40-0.42) between the Australian Dietary Guidelines and the NOVA system, with 69.8% of products aligned across the two systems. Alignment was more common for discretionary foods (80.6% were ultra-processed) than core foods (59.9% aligned were not-ultra-processed). Food categories exhibiting the strongest levels of alignment included confectionary, foods for specific dietary use, and egg and egg products. Discordance was most common for convenience foods, sugars, honey and related products, and cereal and grain products. CONCLUSIONS: Despite moderate alignment between the Australian Dietary Guidelines and NOVA, the discordance observed for almost one-third of products highlights the opportunity to develop recommendations for ultra-processed foods within the guidelines to advise Australians how these foods should be considered as part of a healthy diet.

Aligning front-of-pack labelling with dietary guidelines: including whole grains in the health star rating.

PURPOSE: Front-of-pack labelling systems, such as the Health Star Rating (HSR), aim to aid healthy consumer dietary choices and complement national dietary guidelines. Dietary guidelines aim to be holistic by extending beyond the individual nutrients of food, including other food components that indicate diet quality, including whole grains. We aimed to test the feasibility of including whole grains in the HSR algorithm, to better inform dietary guidance in Australia coherent with existing dietary guidelines. METHODS: We assigned whole-grain points as a favourable component of the HSR based on the whole-grain content of foods. We compared the original, and three modified HSR algorithms (including altered thresholds for star ratings) using independent-samples median tests. Finally, we used Spearman's correlation to measure the strength of association between an item's nutritional composition (all components of the HSR algorithm including all favourable and unfavourable components) and their HSR using each algorithm. RESULTS: Up to 10 points were added for products with ≥ 50% whole-grain content, with no points for products with < 25%. Adjusting the HSR score cut-off by 3 points for grain products created the greatest difference in median HSR between refined and whole-grain items (up to 2 stars difference), compared to the original algorithm (a maximum of 1 star). CONCLUSIONS: The addition of whole grains to the HSR algorithm improved the differentiation of refined and whole-grain items, and therefore better aligned with dietary guidelines. Holistic approaches to food guidance systems are required to provide consistent messaging and inform positive food choices.

Aboriginal and Torres Strait Islander peoples' Quitline use and the Tackling Indigenous Smoking program.

OBJECTIVE: The Australian Government Tackling Indigenous Smoking (TIS) program aims to reduce tobacco use among Aboriginal and Torres Strait Islander peoples, delivering locally tailored health promotion messages, including promoting the Quitline. We aimed to analyse data on use of the Quitline by Aboriginal and Torres Strait Islander peoples nationally, specifically in TIS and non-TIS areas. METHODS: We analysed usage of the Quitline in seven jurisdictions across Australia in areas with and without TIS teams (TIS areas and non-TIS areas respectively) between 2016-2020. Demographic and usage characteristics were quantified. Clients and referrals as a proportion of the current smoking population were calculated for each year, 2016-2020. RESULTS: From 2016-2020, 12 274 Aboriginal and Torres Strait Islander people were clients of the Quitline in included jurisdictions. Most (69%) clients were living in a TIS area. Two-thirds (66.4%) of referrals were from third­party referrers rather than self-referrals. Overall, between 1.25% and 1.62% of Aboriginal and Torres Strait Islander peoples who currently smoked were clients of Quitline (between 1.15-1.57% in TIS areas and 0.82-0.97% in non-TIS areas). CONCLUSIONS: The Quitline provided smoking cessation support to approximately 2500-3000 Aboriginal and Torres Strait Islander clients annually between 2016-2020. Referrals from third parties including Aboriginal and Torres Strait Islander services are an important pathway connecting community members to an evidenced-based cessation support service.

The social determinants of Aboriginal and Torres Strait Islander adults who do not smoke in regional Australia.

INTRODUCTION: Commercial tobacco use was systematically embedded as a valuable commodity through colonisation that continues to be exploited for profit by the Tobacco Industry. There have been significant declines in current smoking prevalence among Aboriginal and Torres Strait Islander peoples 18 years and over, from 55% in 1994 to 43% in 2018-2019. This paper seeks to better understand smoke-free behaviours, and to systematically quantify associations between a range of SDOH and non-smoking/never-smoking among Aboriginal and Torres Strait Islander adults (≥18) living in regional Australia. OBJECTIVE: To explore the social determinants of health (SDOH) related to non- and never-smoking among Aboriginal and Torres Strait Islander peoples in regional Australia. DESIGN: Cross-sectional analysis of the NATSIHS, weighted to the Aboriginal and Torres Strait Islander adult population living in regional Australia, was conducted. Participants were characterised as people who were current smokers, never-smokers and non-smokers (ex- and never-smokers). The social determinants of health exposures related to socioeconomic position, well-being and access to healthcare. SETTING: Regional Australia is distinct from urban and remote areas, based on the ASGS Remoteness Structure (ABS) 2018-2019. PARTICIPANTS: Aboriginal and Torres Strait Islander adults (≥18 years) who were selected, consented and asked questions about smoking in the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS 2018/19). RESULTS: High income was associated with non-smoking (Prevalence Ratio [PR] = 2.07; 95% CI: 1.66-2.57) and never-smoking (PR = 2.02; 1.46-2.79), as was completing year 10 (non-smoking PR = 1.34; 1.12-1.61 and never-smoking PR = 1.56; 1.20-2.03). Better food security was associated with a higher prevalence of never-smoking (PR = 2.42; 1.48-3.98). Lower psychological distress scores were associated with non-smoking (PR = 1.30; 1.10-1.53) and never-smoking (PR = 1.56; 1.21-2.01). Never-smoking was more frequent in participants reporting no experiences of unfair treatment (PR = 1.59; 1.22-2.06). Having a usual healthcare provider was associated with non-smoking (PR = 1.38; 1.02-1.86). Positive exposure to the SDOH were associated with non- and never-smoking among Aboriginal and Torres Strait Islander adults in regional Australia. Structural and systemic changes to address the SDOH, including discrimination and racism, are expected to accelerate non-smoking behaviours and improve health outcomes for Aboriginal and Torres Strait Islander peoples.

Criterion validation of nutrient profiling systems: a systematic review and meta-analysis.

BACKGROUND: Nutrient profiling systems (NPSs) use algorithms to evaluate the nutritional quality of foods and beverages. Criterion validation, which assesses the relationship between consuming foods rated as healthier by the NPS and objective measures of health, is essential to ensure the accuracy of NPSs. OBJECTIVE: We examined and compared NPSs that have undergone criterion validity testing in relation to diet-related disease risk and risk markers. METHODS: Academic databases were searched for prospective cohort and cross-sectional studies published before November, 2022. NPSs were eligible if they incorporated multiple nutrients or food components using an algorithm to determine an overall summary indicator (e.g., a score or rank) for individual foods. Studies were included if they assessed the criterion validity of an eligible NPS. Validation evidence was first summarized in narrative form by NPS, with random effects meta-analysis where ≥2 prospective cohort studies assessed the same NPS and outcomes. RESULTS: Of 4519 publications identified, 29 describing 9 NPSs were included in the review. The Nutri-Score NPS was assessed as having substantial criterion validation evidence. Highest compared with lowest diet quality as defined by the Nutri-Score was associated with significantly lower risk of cardiovascular disease (hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.59, 0.93; n = 6), cancer (HR: 0.75; 95% CI: 0.59, 0.94; n = 5), all-cause mortality (HR: 0.74; 95% CI; 0.59, 0.91; n = 4) and change in body mass index (HR: 0.68; 95% CI: 0.50, 0.92; n = 3). The Food Standards Agency NPS, Health Star Rating, Nutrient Profiling Scoring Criterion, Food Compass, Overall Nutrition Quality Index, and the Nutrient-Rich Food Index were determined as having intermediate criterion validation evidence. Two other NPSs were determined as having limited criterion validation evidence. CONCLUSIONS: We found limited criterion validation studies compared with the number of NPSs estimated to exist. Greater emphasis on conducting and reporting on criterion validation studies across varied contexts may improve the confidence in existing NPSs.

Comparing product healthiness according to the Health Star Rating and the NOVA classification system and implications for food labelling systems: An analysis of 25 486 products in Australia.

We investigated the extent of alignment between 'healthiness' defined by a food classification system that classifies foods and beverages primarily by their nutrient composition, the Health Star Rating (HSR) and a system that considers only the degree of processing of the product, the NOVA classification system. We used data for 25 486 products contained within the George Institute for Global Health's Australian 2022 FoodSwitch Dataset. Agreement between the two systems in the proportion of products classified as 'healthier' (HSR ≥3.5 or NOVA group 1-3) or 'less healthy' (HSR <3.5 or NOVA group 4) was assessed using the κ statistic. There was 'fair' agreement (κ = 0.30, 95%CI: 0.29-0.31) between both systems in the proportion of all products classified as healthier or less healthy. Approximately one-third (n = 8729) of all products were defined as 'discordant', including 34.3% (n = 5620) of NOVA group 4 products with HSR ≥3.5 (commonly convenience foods, sports/diet foods, meat alternatives, as well as products containing non-sugar sweeteners) and 34.1% (n = 3109) of NOVA group 1-3 products with HSR <3.5 (commonly single-ingredient foods such as sugars/syrups, full-fat dairy and products specially produced to contain no ultra-processed ingredients). Our analysis strengthens the evidence for the similarities and differences in product healthiness according to a nutrient-based classification system and a processing-based classification system. Although the systems' classifications align for the majority of food and beverage products, the discordance found for some product categories indicates potential for confusion if systems are deployed alongside each other within food policies.

The Effect of Retail Food Environment Interventions on Dietary Behavior in Postsecondary Education Settings: A Systematic Review and Meta-analysis.

BACKGROUND: Postsecondary education institutions, where hundreds of millions of people work and study globally, are a key setting for retail food environment interventions. OBJECTIVE: We aimed to synthesize the evidence for the effectiveness of retail food environment interventions in improving the healthiness of dietary behavior of students and staff in postsecondary education settings. METHODS: Academic databases were searched for randomized controlled trials (RCTs) and quasi-experimental studies published until August 2023. Studies were eligible if they assessed the impact of a retail food environment intervention on healthiness of dietary behavior (purchases or consumption) in students or staff in postsecondary education settings and targeted one of the following food environment elements: placement, price, product, or promotion. Business-related outcomes (total sales, profit, or revenue) were included as secondary outcomes. Findings were synthesized in narrative form, organized by retail food environment element. Where comparable dietary outcome data were available from ≥10 interventions, findings were pooled using random effects meta-analysis. RESULTS: Of 10,126 studies initially identified, 55 (76% quasi-experimental) were included, describing 71 separate interventions (n = 49 single-element and n = 22 multi-element). Two-thirds (n = 47, 66%) of interventions (n = 32 single-element and n = 15 multi-element) demonstrated significant improvements in dietary behavior. Single-element interventions targeting placement (n = 1) and price (n = 3) improved dietary behavior. Most (n = 9/10, 90%) interventions targeting product availability or convenience (product element) improved dietary behavior, while n = 19/35 (54%) targeting promotion did. Pooled findings from 12 interventions reporting changes in energy content demonstrated a significant decrease in purchased or consumed energy (-7.9%; 95% confidence interval: -10.3%, -5.6%). Almost all interventions (n = 11/12, 92%) that evaluated the impact on business-related outcomes found either a significant increase or no change following the intervention. CONCLUSIONS: We established encouraging evidence supporting the role of retail food environment interventions in postsecondary education settings to support healthy dietary behaviors of students and staff. REGISTRY: PROSPERO (International Prospective Register of Systematic Reviews, URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295836; registration number CRD42022295836).

Protocol for a randomized controlled trial of medically tailored meals compared to usual care among individuals with type 2 diabetes in Australia.

BACKGROUND: 'Food is medicine' strategies aim to integrate food-based nutrition interventions into healthcare systems and are of growing interest to healthcare providers and policy makers. 'Medically Tailored Meals' (MTM) is one such intervention, which involves the 'prescription' by healthcare providers of subsidized, pre-prepared meals for individuals to prevent or manage chronic conditions, combined with nutrition education. OBJECTIVE: This study will test the efficacy of an MTM program in Australia among participants with type 2 diabetes (T2D) and hyperglycemia, who experience difficulties accessing and eating nutritious food. METHODS: This study will be a two-arm parallel trial (goal n = 212) with individuals randomized in a 1:1 ratio to a MTM intervention group or a control group (106 per arm). Over 26 weeks, the intervention group will be prescribed 20 MTM per fortnight and up to 3 sessions with an accredited dietitian. Controls will continue with their usual care. The primary outcome is glycated hemoglobin (HbA1c, %) and secondary outcomes include differences in blood pressure, blood lipids and weight, all measured at 26 weeks. Process and economic data will be analyzed to assess the feasibility, acceptability, scalability, and cost-effectiveness of the intervention. Recruitment commenced in the first quarter of 2023, with analyses and results anticipated to be available by March 2025. DISCUSSION: Few randomized controlled trials have assessed the impact of MTM on clinical outcomes. This Australian-first trial will generate robust data to inform the case for sustained, large-scale implementation of MTM to improve the management of T2D among vulnerable populations. ANZCTR: ACTRN12622000852752. PROTOCOL VERSION: Version 1.1, July 2023.

The Nutritional Quality of Gluten-Free versus Non-Gluten-Free Pre-Packaged Foods and Beverages Sold in Hong Kong.

INTRODUCTION: The consumption of gluten-free foods has continued to increase in recent years. Given their higher intake among individuals both with and without a medically diagnosed gluten allergy or sensitivity, it is important to understand how the nutritional quality of these foods compares against non-gluten-free foods. As such, we aimed to compare the nutritional quality of gluten-free and non-gluten-free pre-packaged foods sold in Hong Kong. METHODS: Data from 18,292 pre-packaged food and beverage items in the 2019 FoodSwitch Hong Kong database were used. These products were categorized as (1) "declared gluten-free"; (2) "gluten-free by ingredient or naturally gluten-free"; and (3) "non-gluten-free" according to information presented on the package. One-way ANOVA was used to compare the differences in the Australian Health Star Rating (HSR), energy, protein, fibre, total fat, saturated fat, trans-fat, carbohydrates, sugars, and sodium content between products in different gluten categories, overall and by major food category (e.g., bread and bakery products) and region of origin (e.g., America, Europe). RESULTS: Products declared gluten-free (mean ± SD: 2.9 ± 1.3; n = 7%) had statistically significantly higher HSR than those gluten-free by ingredient or naturally gluten-free (2.7 ± 1.4; n = 51.9%) and non-gluten-free (2.2 ± 1.4; n = 41.2%) (all pairwise comparisons p < 0.001). Overall, non-gluten-free products have higher energy, protein, saturated fat, trans-fat, free sugar and sodium, and less fibre compared with products in the other two gluten categories. Similar differences were observed across major food groups and by region of origin. CONCLUSIONS: Non-gluten-free products sold in Hong Kong were generally less healthy than gluten-free products (regardless of the presence of gluten-free declaration). Consumers should be better educated on how to identify gluten-free foods, given that many gluten-free foods do not declare this information on the label.

A Cross-Sectional Evaluation of the Food Environment at an Australian University Campus.

University food environments have a strong influence on the dietary choices of students and staff. The aim of this study was to assess the food environment at a large university in Sydney, Australia. Data were collected between March and July 2022 from 27 fixed food outlets and 24 vending machines. The healthiness of the food environment was evaluated using the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework ('Framework'), which assesses food environment parameters including the availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. Each parameter was evaluated overall and across each food outlet type. Across all outlets, Everyday foods and drinks made up 43.9% of all products. Only two outlets met the Framework's product availability benchmark of ≥75% Everyday foods and drinks. A total of 43 outlets (84.3%) sold sugary drinks as part of their product range. Occasional products made up 68.4%, 53.3%, and 59.9% of all items for sale at checkout areas, countertops, and eye-level shelves, respectively. Finally, 79.7% of meal deals included Occasional products. Our findings highlight the need to improve the availability, placement, and promotion of foods and drinks sold at a major university campus in Sydney, Australia.

Estimating population coverage of Tackling Indigenous Smoking teams, a placed-based health intervention in Australia.

OBJECTIVE: As part of the Tackling Indigenous Smoking (TIS) program, TIS teams provide Aboriginal and Torres Strait Islander-led tobacco control in their geographic area. We aimed to estimate the percentage and number of Aboriginal and Torres Strait Islander peoples living in an area serviced by a TIS team in 2018-19. METHODS: We analysed weighted, representative data from 8,048 Aboriginal and Torres Strait Islander people aged ≥10 years from the 2018-19 National Aboriginal and Torres Strait Islander Health Survey. TIS services mapping data were used to define areas served by TIS teams. Coverage was explored in relation to remoteness, program priority groups and sociodemographic characteristics. RESULTS: Around three-quarters (76.4%,95%CI:72.9-79.9) of the 2018-19 population aged ≥10 years lived in an area served by TIS teams (n=479,000). Coverage by TIS teams was generally similar across groups, with few exceptions. CONCLUSIONS: The recently announced expansion to national coverage would provide access to locally tailored tobacco control to a further 148,000 Aboriginal and Torres Strait Islander peoples aged ≥10 years, including 46,000 adults who currently smoke. IMPLICATIONS FOR PUBLIC HEALTH: Expansion to national TIS team coverage is a welcomed first step on the path to ensuring equitable access to tobacco control.

Smoking cessation support strategies for Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study.

OBJECTIVE: To identify smoking cessation support strategies that resonate with Aboriginal and Torres Strait Islander women. DESIGN, SETTING AND PARTICIPANTS: A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020. MAIN OUTCOME MEASURES: Preferred strategies, providers and locations for smoking cessation support. RESULTS: Among a total of 428 women who participated in the survey, group-based support and holistic support were the most preferred strategies (preferred by 31.8% and 22.2% of women, respectively). Use of an Aboriginal health service was positively associated with choosing holistic support programs (prevalence ratio, 1.14 [95% CI, ≥ 1.00-1.28]). Women with high or moderate nicotine dependency were more likely to consider group-based support to be helpful (prevalence ratio, 1.13 [95% CI, ≥ 1.00-1.27]) than those with low nicotine dependency. The most preferred providers for smoking cessation support were Aboriginal health workers (64.3%). Most women (73.4%) preferred face-to-face support at an Aboriginal health service, 38.8% preferred online support and 34.8% preferred phone support. A higher percentage of older women (≥ 35 years) preferred online or phone support (prevalence ratio, 1.70 [95% CI, 1.03-2.80]) compared with younger women (16-20 years). Use of an Aboriginal health service was positively associated with preference for an Aboriginal health worker (prevalence ratio, 1.35 [95% CI, 1.12-1.62]), and receiving face-to-face support at an Aboriginal health service (prevalence ratio, 1.28 [95% CI, 1.10-1.49]). CONCLUSION: Aboriginal and Torres Strait Islander women prefer a range of cessation supports, with most women preferring group support and holistic approaches. Cessation supports that resonated with women varied by age, remoteness, nicotine dependence, and whether participants used an Aboriginal health service. Women want support to quit smoking from the Aboriginal health workers at their Aboriginal health service, at their health care providers and in their community. Comprehensive, multifaceted supports are required. Online support and phone-based support are also preferred by some women, which helps to increase accessibility. Appropriate models of care - including sufficient funding for Aboriginal health services and Aboriginal health workers - are required and should be developed in partnership with communities to implement meaningful and culturally safe cessation care. This research demonstrates the need for and importance of multifaceted, comprehensive cessation support strategies.

Smoking and quitting characteristics of Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study.

OBJECTIVE: To describe smoking characteristics, quitting behaviour and other factors associated with longest quit attempt and the use of nicotine replacement therapy (NRT) and stop-smoking medication (SSM) in a population of Indigenous Australian women of reproductive age. DESIGN, SETTING AND PARTICIPANTS: A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020. MAIN OUTCOME MEASURES: Quitting experience: attempt to cut down, time since last quit attempt, longest period without smoking, attempt to cut down during last quit attempt, any use of NRT and/or SSM. RESULTS: Most of the 428 participating women (302 [70.6%]) reported using an Aboriginal health service. Younger women (16-20-year-olds) smoked fewer cigarettes daily (24/42 [57.1%], 0-5 cigarettes per day), waited longer to smoke after waking (20/42 [47.6%], > 60 minutes after waking), and were categorised as low smoking dependency compared with those aged 35 years and over. One-third of women (153 [35.7%]) had ever used NRT and/or SSM. A greater proportion of older women (35-49-year-olds) had sustained a quit attempt for years (62/149 [45.6%]) and reported trying NRT and/or SSM (78/149 [52.4%]) than women in younger age groups. Quitting suddenly rather than gradually was significantly associated with sustained abstinence (prevalence ratio, 1.27 [95% CI, 1.10-1.48]). Among women who had never used NRT or SSM, most (219/275 [79.6%]) reported reasons for this in the category of attitudes and beliefs. NRT and SSM use was also more likely among women who were confident talking to their doctor about quitting (odds ratio, 2.50 [95% CI, 1.23-5.10]) and those who received most of their information from a health professional (odds ratio, 1.71 [95% CI, 1.11-2.63]). CONCLUSION: Aboriginal and Torres Strait Islander women want to quit smoking and are making attempts to quit. Quitting suddenly, rather than reducing cigarette consumption, is associated with increased sustained abstinence. Health providers can enable access and uptake of NRT and/or SSM and should recognise that NRT and/or SSM use may change over time. Consistent messaging, frequent offers of smoking cessation support, and access to a range of smoking cessation supports should be provided to Aboriginal and Torres Strait Islander women to enable them to be smoke-free.

Clearing the air: underestimation of youth smoking prevalence associated with proxy-reporting compared to youth self-report.

BACKGROUND: Smoking remains a leading cause of disease burden globally. Declining youth smoking prevalence is an essential feature of effective tobacco control; however, accurate data are required to assess progress. This study investigates bias in youth smoking prevalence estimates by respondent type (proxy-reported, self-report with parent present, or self-report independently) for Aboriginal and Torres Strait Islander and total populations of Australia. METHODS: Repeated cross-sectional analysis of representative Aboriginal and Torres Strait Islander Health and National Health Surveys, 2007-2019. Data were restricted to participants aged 15-17 years. Prevalence ratios (PR) and 95% Confidence Intervals (CI) for ever-smoking by respondent type were calculated using Poisson regression with robust standard errors. National youth current-smoking prevalence was estimated if all data were collected by youth self-report; estimates and trends were compared to observed estimates. RESULTS: Over 75% of all smoking status data were reported by proxy or with parent present. Ever-smoking prevalence among youth self-reporting independently versus proxy-reported was 1.29 (95% CI:0.96-1.73) to 1.99 (95% CI:1.39-2.85) times as high for Aboriginal and Torres Strait Islander youth, and 1.83 (95% CI:0.92-3.63) to 2.72 (95% CI:1.68-4.41) times as high for total population youth. Across surveys, predicted national current-smoking prevalence if all youth self-reported independently was generally higher than observed estimate. CONCLUSIONS: Estimates of youth smoking prevalence are likely inaccurate and underestimated if data are collected by proxy or with parent present. Increased reliance on data reported by youth independently is crucial to improve data accuracy, including to enable accurate assessment of national prevalence.