Cairns Mental Health Co-Responder Project: Essential elements and challenges to programme implementation.

In Australia and internationally, co-responder models are becoming an increasingly common intervention to respond to police callouts where there is an assumed mental health-related component or crisis. This type of model involves a collaborative approach where trained police officers team with mental health clinicians to provide specialized responses in order to improve outcomes for persons with mental illness. However, there is limited understanding as to major elements required for implementation of the model. This study aims to identify the essential elements and challenges in implementation of the Mental Health Co-Responder Project in Cairns, Australia, where the team consists of a mental health nurse with demonstrated competencies in crisis intervention and a specially trained police officer. In 2016, 39 participants completed semi-structured interviews regarding knowledge and experience of the Cairns co-responder model. The participants represented first responders and community-based service providers who work with and support persons living with mental illness. Using a thematic analysis approach, key elements identified as essential to successful project implementation were as follows: co-responder team characteristics, senior and project executive level support, collaborative project governance, and co-location of the team within a mental health setting. The main perceived challenges to project implementation included the following: initial concerns regarding client confidentiality, lack of an evaluation plan, and adequate project resourcing. Governance through a vigorous joint agency operation committee and adequate resourcing is imperative to the sustainability of this model.

Are we there yet? Exploring the journey to quality stroke care for Aboriginal and Torres Strait Islander peoples in rural and remote Queensland.

INTRODUCTION: The burden of stroke for Aboriginal and Torres Strait Islander peoples in Australia is significant. The National Stroke Foundation has identified that Aboriginal and Torres Strait Islander people are more likely to have a stroke at a younger age than the non-Indigenous population and are twice as likely for stroke to result in death, and that those Aboriginal and Torres Strait Islander people living in rural and remote areas are less likely to have access to an acute stroke unit. The only acute stroke unit in Far North Queensland treats six times more Aboriginal and Torres Strait Islander patients than the Queensland average, a large proportion of whom reside in the rural and remote communities of the Cape and Torres Strait. This article describes part of the qualitative phase of a project titled 'Culturally appropriate stroke services for Aboriginal and Torres Strait Islander people', received Closing the Gap funding to identify the needs of Aboriginal and Torres Strait Islander stroke survivors in Far North Queensland and establish a model of care that is responsive to these needs. METHOD: Data were collected from 24 stroke survivors, 10 carers and 70 stakeholders through surveys. The surveys incorporated open-ended questions and were administered through face to face interviews with participants from across 18 diverse Aboriginal and Torres Strait Islander communities within Far North Queensland. Guided by the principles of thematic analysis the data were coded, categories created and themes and subthemes identified. RESULTS: This study emphasises the need for an inclusive coordinated and culturally responsive approach to Aboriginal and Torres Strait Islander stroke care that values the role of the client, their family and community. The Aboriginal and Torres Strait Islander liaison officer has a pivotal role within the multidisciplinary team. Resources specific to the language, literacy and cultural needs of Aboriginal and Torres Strait Islander stroke survivors are required as is advocacy for the availability and use of Aboriginal and Torres Strait Islander language interpreters. Aboriginal and Torres Strait Islander stroke survivors have limited opportunity to fulfil their rehabilitation potential after hospital discharge. CONCLUSION: An integrated patient centred model of care that spans the care continuum and places value on an extended role for the Aboriginal and Torres Strait Islander health worker workforce is indicated, as is an increased utilisation of allied health and specialist follow-up close to home.

Interventions to encourage smoke-free homes in remote indigenous Australian communities: a study protocol to evaluate the effects of a community-inspired awareness-raising and motivational enhancement strategy.

INTRODUCTION: Rates of secondhand smoke exposure are currently significantly higher among remote indigenous communities in the top end of Australia. By implementing a 'smoke-free home' rule, secondhand smoke exposure can be reduced. Smoke-free homes encourage quit attempts and improve the health of children. The prevalence of indigenous smoking rates in remote, discrete communities in Australia is elevated compared with their non-indigenous counterparts. The primary aim of this project is to examine the feasibility of conducting a health-driven intervention to encourage community members to make their homes a smoke-free zone. METHODS AND ANALYSIS: This study uses mixed-methods exploratory evaluation design to obtain data from key informants and community householders to assess their willingness to implement a 'smoke-free' rule in their homes. Initial focus groups will provide guidance on intervention content and deliver evaluation procedures and community requirements. A rapid survey will be conducted to ascertain interest from community members in having the project team visit to discuss study objectives further and to have a particle meter (with consent) placed in the house. Focus groups recordings will be transcribed and analysed thematically. Rapid surveys will be analysed using frequency distributions and tabulations of responses. ETHICS AND DISSEMINATION: The National Health and Medical Research Council guidelines on ethical research approaches to indigenous studies will be adhered to. The James Cook University Human Research Ethics Committee has provided ethics approval.

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review.

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents' motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

'Sly grog' and 'homebrew': a qualitative examination of illicit alcohol and some of its impacts on Indigenous communities with alcohol restrictions in regional and remote Queensland (Australia).

BACKGROUND: Indigenous communities in Queensland (Australia) have been subject to Alcohol Management Plans since 2002/03, with significant penalties for breaching restrictions. 'Sly grog' and 'homebrew' provide access to alcohol despite restrictions. This paper describes how this alcohol is made available and the risks and impacts involved. In affected towns and communities across a large area of rural and remote Queensland, interviews and focus groups documented experiences and views of 255 long-standing community members and service providers. Using an inductive framework, transcribed interviews were analysed to identify supply mechanisms, community and service provider responses and impacts experienced. RESULTS: 'Homebrew' was reportedly manufactured in just a few localities, in locally-specific forms bringing locally-specific harms. However, 'sly grog' sourced from licensed premises located long distances from communities, is a widespread concern across the region. 'Sly grog' sellers circumvent retailers' takeaway liquor license conditions, stockpile alcohol outside restricted areas, send hoax messages to divert enforcement and take extraordinary risks to avoid apprehension. Police face significant challenges to enforce restrictions. On-selling of 'sly grog' appears more common in remote communities with total prohibition. Despite different motives for involvement in an illicit trade 'sly grog' consumers and sellers receive similar penalties. CONCLUSIONS: There is a need for: (a) a more sophisticated regional approach to managing takeaway alcohol sales from licensed suppliers, (b) targeted penalties for 'sly grog' sellers that reflect its significant community impact,

Alcohol management plans in Aboriginal and Torres Strait Islander (Indigenous) Australian communities in Queensland: community residents have experienced favourable impacts but also suffered unfavourable ones.

BACKGROUND: In Australia, 'Alcohol Management Plans' (AMPs) provide the policy infrastructure for State and Commonwealth Governments to address problematic alcohol use among Aboriginal and Torres Strait Islanders. We report community residents' experiences of AMPs in 10 of Queensland's 15 remote Indigenous communities. METHODS: This cross-sectional study used a two-stage sampling strategy: N = 1211; 588 (48%) males, 623 (52%) females aged ≥18 years in 10 communities. Seven propositions about 'favourable' impacts and seven about 'unfavourable' impacts were developed from semi-structured interviews. For each proposition, one-sample tests of proportions examined participant agreement and multivariable binary logistic regressions assessed influences of gender, age (18-24, 25-44, 45-64, ≥65 years), residence (≥6 years), current drinking and Indigenous status. Confirmatory factor analyses estimated scale reliability (ρ), item loadings and covariances. RESULTS: Slim majorities agreed that: AMPs reduced violence (53%, p = 0.024); community a better place to live (54%, 0.012); and children were safer (56%, p < 0.001). More agreed that: school attendance improved (66%, p < 0.001); and awareness of alcohol's harms increased (71%, p < 0.001). Participants were equivocal about improved personal safety (53%, p = 0.097) and reduced violence against women (49%, p = 0.362). The seven 'favourable' items reliably summarized participants' experiences of reduced violence and improved community amenity (ρ = 0.90). Stronger agreement was found for six 'unfavourable' items: alcohol availability not reduced (58%, p < 0.001); drinking not reduced (56%, p < 0.001)); cannabis use increased (69%, p < 0.001); more binge drinking (73%, p < 0.001); discrimination experienced (77%, p < 0.001); increased fines, convictions and criminal records for breaching restrictions (90%, p < 0.001). Participants were equivocal (51% agreed, p = 0.365) that police could enforce restrictions effectively. 'Unfavourable' items were not reliably reflected in one group (ρ = 0.48) but in: i) alcohol availability and consumption not reduced and ii) criminalization and discrimination. In logistic regressions, longer-term (≥ 6 years) residents more likely agreed that violence against women had reduced and that personal safety had improved but also that criminalization and binge drinking had increased. Younger people disagreed that their community was a better place to live and strongly agreed about discrimination. Current drinkers' views differed little from the sample overall. CONCLUSIONS: The present Government review provides an opportunity to reinforce 'favourable' outcomes while targeting: illicit alcohol, treatment and diversion services and reconciliation of criminalization and discrimination issues.

Unintended impacts of alcohol restrictions on alcohol and other drug use in Indigenous communities in Queensland (Australia).

BACKGROUND: 'Alcohol Management Plans' (AMPs) with a focus on alcohol restrictions were implemented in 19 discrete Indigenous communities, in 15 Local Government Areas, by the Queensland Government from 2002. Community residents' perceptions and experiences of the impacts of AMPs on local alcohol and drug use are documented. METHODS: A cross-sectional study used quantitative and qualitative survey data collected during 2014-2015 in 10 affected communities. Five had some alcohol available. Five had total prohibition. Participant responses were assessed and compared by prohibition status. RESULTS: Overall, less than 50% of 1098 participants agreed that: i) the restrictions had reduced alcohol availability in their community and ii) that people were drinking less. Nearly three quarters agreed that binge-drinking had increased, attributed to increased availability of illicit alcohol. There were no statistically significant differences between communities with prohibition and those with some access to alcohol. Participants agreed overall that cannabis use had increased but were more equivocal that new drugs were being used. These views were less frequently reported in prohibition communities. CONCLUSIONS: Contrary to what was intended, Queensland's alcohol restrictions in Indigenous communities were viewed by community residents as not significantly reducing the availability and use of alcohol. Furthermore, this was compounded by perceived increases in binge drinking and cannabis use; also unintended. There is a need to strengthen resolve at all levels to reduce the supply of illicit alcohol in restricted areas.

Alcohol control policies in Indigenous communities: A qualitative study of the perceptions of their effectiveness among service providers, stakeholders and community leaders in Queensland (Australia).

BACKGROUND: Favourable impacts are reported from complex alcohol control strategies, known as 'Alcohol Management Plans' (AMPs) implemented 14 years ago in 19 Aboriginal and Torres Strait Islander (Indigenous) communities in Queensland (Australia). However, it is not clear that all communities benefited and that positive impacts were sustained. Service providers, key stakeholders and community leaders provided insights about issues and impacts. METHODS: Participants (N=382) were recruited from knowledgeable and experienced persons using agency lists and by recommendation across sectors which have a mandate for managing alcohol-related issues and consequences of AMP policies in communities. In semi-structured interviews, participants (51% Indigenous, 55% male and comprised of at least one-third local community residents) were asked whether they believed alcohol controls had been effective and to describe any favourable and unfavourable outcomes experienced or perceived. Inductive techniques were used for thematic analysis of the content of transcribed recorded interviews. Comments reflecting themes were assessed across service sectors, by gender, Indigenous status and remoteness. RESULTS: Participants attributed reduced violence and improved community amenity to AMPs, particularly for 'very remote' communities. Participants' information suggests that these important achievements happened abruptly but may have become undermined over time by: the availability of illicit alcohol and an urgency to consume it; migration to larger centres to seek alcohol; criminalization; substitution of illicit drugs for alcohol; changed drinking behaviours and discrimination. Most issues were more frequently linked with 'very remote' communities. CONCLUSION: Alcohol restrictions in Queensland's Indigenous communities may have brought favourable changes, a significant achievement after a long period of poorly regulated alcohol availability from the 1980s up to 2002. Subsequently, over the past decade, an urgency to access and consume illicit alcohol appears to have emerged. It is not clear that relaxing restrictions would reverse the harmful impacts of AMPs without significant demand reduction, treatment and diversion efforts.

A Review of Trends in Indigenous Australian Tobacco Research (From 2004 to 2013), its Associated Outputs and Evidence of Research Translation.

INTRODUCTION: Smoking prevalence among Indigenous Australians nationally (45%) is more than double that of other Australians but ranges up to 82% in remote communities, causing significant health disparities. This paper examines trends in peer-reviewed research outputs related to Indigenous Australian tobacco control over the past decade and describes their research translation potential and alignment with national and jurisdictional policy priorities. METHODS: Systematic searches of electronic databases were conducted: Medline, CINAHL, Cochrane Systematic Reviews, PsychInfo, and Australian HealthInfoNET for English-language peer-reviewed publications (2004-2013) primarily focusing on Indigenous Australian tobacco use. Publications were categorized by types, topics, and geographic location. Following established procedures, "reviews" and "commentaries" were distinguished from "original research," the latter further classified as "measurement," "descriptive," or "intervention" studies. Research translation categories used were: "synthesis," "dissemination," "exchange," and "application." RESULTS: The majority of 78 publications meeting selection criteria focused on cessation treatment (28%), monitoring and prevalence (24%) and passive smoking (13%). "Original research" was mostly "descriptive/epidemiologic" (81%) with few "intervention" studies (9%). Many studies were in remote communities. Components of research translation were identified in 50% of the publications with little evidence of dissemination strategies. CONCLUSION: Remote community populations are an area of great need. However, generally it is disappointing that since 2004, few intervention studies are available to guide efforts to reduce tobacco-related health disparities. Stronger and more immediate alignment of policy with research that contributes to the evidence-base is required together with more systematic use of research dissemination translation strategies to better match evidence with priorities which may develop rapidly over time.

Study Protocol--Alcohol Management Plans (AMPs) in remote indigenous communities in Queensland: their impacts on injury, violence, health and social indicators and their cost-effectiveness.

BACKGROUND: In 2002/03 the Queensland Government responded to high rates of alcohol-related harm in discrete Indigenous communities by implementing alcohol management plans (AMPs), designed to include supply and harm reduction and treatment measures. Tighter alcohol supply and carriage restrictions followed in 2008 following indications of reductions in violence and injury. Despite the plans being in place for over a decade, no comprehensive independent review has assessed to what level the designed aims were achieved and what effect the plans have had on Indigenous community residents and service providers. This study will describe the long-term impacts on important health, economic and social outcomes of Queensland's AMPs. METHODS/DESIGN: The project has two main studies, 1) outcome evaluation using de-identified epidemiological data on injury, violence and other health and social indicators for across Queensland, including de-identified databases compiled from relevant routinely-available administrative data sets, and 2) a process evaluation to map the nature, timing and content of intervention components targeting alcohol. Process evaluation will also be used to assess the fidelity with which the designed intervention components have been implemented, their uptake and community responses to them and their perceived impacts on alcohol supply and consumption, injury, violence and community health. Interviews and focus groups with Indigenous residents and service providers will be used. The study will be conducted in all 24 of Queensland's Indigenous communities affected by alcohol management plans. DISCUSSION: This evaluation will report on the impacts of the original aims for AMPs, what impact they have had on Indigenous residents and service providers. A central outcome will be the establishment of relevant databases describing the parameters of the changes seen. This will permit comprehensive and rigorous surveillance systems to be put in place and provided to communities empowering them with the best credible evidence to judge future policy and program requirements for themselves. The project will inform impending alcohol policy and program adjustments in Queensland and other Australian jurisdictions.The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4967 & H5241).

"We made the rule, we have to stick to it": towards effective management of environmental tobacco smoke in remote Australian Aboriginal communities.

Smoking prevalence in remote Australian Aboriginal communities remains extraordinarily high, with rates reported of up to 82%. Widespread exposure to environmental tobacco smoke (ETS) is exacerbated by overcrowded housing. Implementation of existing smoke-free policies is challenged by the normalization of smoking and a lack of appropriate regulation resources. This paper celebrates a grassroots approach to control of environmental tobacco smoke (ETS) in these settings. We report on selected findings from a tobacco intervention study in Arnhem Land, Northern Territory in 2007-2012. In community-level tobacco use surveys at baseline (n = 400 ≥ 16 years), participants reported concern about the constant exposure of non-smokers to tobacco smoke. Suggestions for action included restricting smoking in private and public spaces. We selected three case studies illustrating management of ETS from observational data during the study's intervention phase. Using a critical realist approach, the context and mechanisms that contributed to specific strategies, or outcomes, were examined in order to develop a hypothesis regarding more effective management of ETS in these environments. Our results suggest that in discrete, disadvantaged communities, enhanced local ownership of smoke-free policies and development of implementation strategies at the grassroots level that acknowledge and incorporate cultural contexts can contribute to more effective management of ETS.

Aboriginal people in remote communities in Arnhem Land (Northern Territory) restrict their smoking in some environments: Implications for developing and implementing interventions to reduce exposure to environmental tobacco smoke.

INTRODUCTION AND AIMS: In Arnhem Land's remote Aboriginal communities [Northern Territory], very high smoking rates and overcrowding mean high exposure to Environmental Tobacco Smoke. This study compared smokers who restrict their smoking in these environments with those who do not. DESIGN AND METHODS: In 2008-2009, 258 smokers (137 males and 121 females) aged ≥ 16 years, provided information permitting categorisation of those who 'RESTRICT' their smoking in the house, car or workplace from those who do 'NOT RESTRICT'. Univariable and multivariable logistic regressions compared 'RESTRICT' and 'NOT RESTRICT' groups by gender, age group, daily use, tobacco consumption, time-to-first-cigarette and quit intentions. Those in the 'RESTRICT' group explained their motivations, summarised using qualitative data analysis. RESULTS: Men were almost twice as likely to 'NOT RESTRICT' their smoking (odds ratio = 1.88, 95% confidence interval = 1.14-3.08, P = 0.013). Time-to-first-cigarette was the strongest predictor to 'NOT RESTRICT' in women (odds ratio = 3.48, 95% confidence interval = 1.44-8.41, P = 0.006) with daily consumption the strongest predictor in men (odds ratio = 3.15, 95% confidence interval = 1.39-7.18, P = 0.006). Men and women shared similar motivations for restricting smoking. DISCUSSION AND CONCLUSIONS: Smoke-free homes and workplaces are important opportunities to reduce exposure to Environmental Tobacco Smoke in remote Indigenous communities.

Addressing high rates of smoking in remote Aboriginal communities--new evidence for GPs.

OBJECTIVE: To inform smoking interventions by clinicians, particularly doctors, in primary healthcare settings in remote Aboriginal communities, we describe the results of tobacco surveys in remote Northern Territory communities. METHODS: During 2008-09 in three remote communities in the Northern Territory, 400 people (aged ≥16 years) were asked about their tobacco use. RESULTS: Extremely high rates of smoking persist: 71%, 78% and 82% of those interviewed in the three communities. More than half the smokers were either thinking about or actively trying to quit, despite limited access to appropriate support. Among former smokers, the most common motivator for quitting was 'health concerns'. Of those citing 'health concerns', 22% specifically mentioned receiving advice from a clinician, usually a 'doctor'. CONCLUSION: General practitioners, and their colleagues in similar primary healthcare settings, are well placed and are strongly encouraged to take every opportunity to make what could be a significant impact on reducing harms related to smoking and environmental smoke.

Translation of tobacco policy into practice in disadvantaged and marginalized subpopulations: a study of challenges and opportunities in remote Australian Indigenous communities.

BACKGROUND: In Australia generally, smoking prevalence more than halved after 1980 and recently commenced to decline among Australia's disadvantaged Indigenous peoples. However, in some remote Indigenous Australian communities in the Northern Territory (NT), extremely high rates of up to 83% have not changed over the past 25 years. The World Health Organisation has called for public health and political leadership to address a global tobacco epidemic. For Indigenous Australians, unprecedented policies aim to overcome disadvantage and close the 'health gap' with reducing tobacco use the top priority. This study identifies challenges and opportunities to implementing these important new tobacco initiatives in remote Indigenous communities. METHODS: With little empirical evidence available, we interviewed 82 key stakeholders across the NT representing operational- and management-level service providers, local Indigenous and non-Indigenous participants to identify challenges and opportunities for translating new policies into successful tobacco interventions. Data were analysed using qualitative approaches to identify emergent themes. RESULTS: The 20 emergent themes were classified using counts of occasions each theme occurred in the transcribed data as challenge or opportunity. The 'smoke-free policies' theme occurred most frequently as opportunity but infrequently as challenge while 'health workforce capacity' occurred most frequently as challenge but less frequently as opportunity, suggesting that policy implementation is constrained by lack of a skilled workforce. 'Smoking cessation support' occurred frequently as opportunity but also frequently as challenge suggesting that support for individuals requires additional input and attention. CONCLUSIONS: These results from interviews with local and operational-level participants indicate that current tobacco policies in Australia targeting Indigenous smoking are sound and comprehensive. However, for remote Indigenous Australian communities, local and operational-level participants' views point to an 'implementation gap'. Their views should be heard because they are in a position to provide practical recommendations for effective policy implementation faithful to its design, thereby translating sound policy into meaningful action. Some recommendations may also find a place in culturally diverse low- and middle-income countries. Key words: tobacco policy implementation, challenges, opportunities, remote Indigenous Australian communities.

Can we measure daily tobacco consumption in remote indigenous communities? Comparing self-reported tobacco consumption with community-level estimates in an Arnhem Land study.

INTRODUCTION AND AIMS: In remote Indigenous Australian communities measuring individual tobacco use can be confounded by cultural expectations, including sharing. We compared self-reported tobacco consumption with community-level estimates in Arnhem Land (Northern Territory). DESIGN AND METHODS: In a cross-sectional survey in three communities (population 2319 Indigenous residents, aged ≥16 years), 400 Indigenous residents were interviewed (206 men, 194 women). Eight community stores provided information about tobacco sold during the survey. To gauge the impact of 255 non-Indigenous residents on tobacco turnover, 10 were interviewed (five men, five women). Breath carbon monoxide levels confirmed self-reported smoking. Self-reported number of cigarettes smoked per day was compared with daily tobacco consumption per user estimated using amounts of tobacco sold during 12 months before the survey (2007-2008). 'Lighter smokers' (<10 cigarettes per day) and 'heavier smokers' (≥10 cigarettes per day) in men and women were compared. RESULTS: Of 400 Indigenous study participants, 305 (76%) used tobacco; four chewed tobacco. Of 301 Indigenous smokers, 177 (58%) provided self-reported consumption information; a median of 11-11.5 cigarettes per day in men and 5.5-10 cigarettes per day in women. Men were three times (odds ratio=2.9) more likely to be 'heavier smokers'. Store turnover data indicated that Indigenous tobacco users consumed the equivalent of 9.2-13.1 cigarettes per day; very similar to self-reported levels. Sixty per cent (=6/10) of non-Indigenous residents interviewed were smokers, but with little impact on tobacco turnover overall (2-6%). DISCUSSION AND CONCLUSIONS: Smoking levels reported by Indigenous Australians in this study, when sharing tobacco was considered, closely reflected quantities of tobacco sold in community stores.

A review of the barriers preventing Indigenous Health Workers delivering tobacco interventions to their communities.

OBJECTIVE: To review available literature addressing the issue of whether smoking status of Indigenous Health Workers (IHWs) impedes provision of health information about smoking tobacco to their communities. METHOD: Databases were searched for publications that examined IHWs' smoking status or quit support programs for IHWs. Studies were categorised as reviews and commentaries, intervention studies or descriptive research. RESULTS: Fourteen studies met inclusion criteria. Overall, the literature suggests that IHWs' smoking status is a barrier. However, the poor quality of most studies weakens the evidence for this conclusion. The issue of IHWs smoking status as a barrier is peripheral to all but two of the studies. Literature cited and reviewed was often not exhaustive and relied on only a few preceding empirical studies. Most studies were unclear about whether IHWs' views were reported as distinct from views of health staff in general. CONCLUSIONS AND IMPLICATIONS: The recent COAG investment to Tackling Smoking is an important contribution to Closing the Gap in the health of Indigenous Australians. However, there remain potential barriers faced by IHWs that may undermine efforts to reduce Indigenous smoking. Overcoming these barriers and assisting IHWs to quit smoking may provide an opportunity to address high rates of smoking in Indigenous communities. Further research is required with a balance between descriptive research to assess the issue and intervention research to address it.

Using breath carbon monoxide to validate self-reported tobacco smoking in remote Australian Indigenous communities.

BACKGROUND: This paper examines the specificity and sensitivity of a breath carbon monoxide (BCO) test and optimum BCO cutoff level for validating self-reported tobacco smoking in Indigenous Australians in Arnhem Land, Northern Territory (NT). METHODS: In a sample of 400 people (>/=16 years) interviewed about tobacco use in three communities, both self-reported smoking and BCO data were recorded for 309 study participants. Of these, 249 reported smoking tobacco within the preceding 24 hours, and 60 reported they had never smoked or had not smoked tobacco for >/=6 months. The sample was opportunistically recruited using quotas to reflect age and gender balances in the communities where the combined Indigenous populations comprised 1,104 males and 1,215 females (>/=16 years). Local Indigenous research workers assisted researchers in interviewing participants and facilitating BCO tests using a portable hand-held analyzer. RESULTS: A BCO cutoff of >/=7 parts per million (ppm) provided good agreement between self-report and BCO (96.0% sensitivity, 93.3% specificity). An alternative cutoff of >/=5 ppm increased sensitivity from 96.0% to 99.6% with no change in specificity (93.3%). With data for two self-reported nonsmokers who also reported that they smoked cannabis removed from the analysis, specificity increased to 96.6%. CONCLUSION: In these disadvantaged Indigenous populations, where data describing smoking are few, testing for BCO provides a practical, noninvasive, and immediate method to validate self-reported smoking. In further studies of tobacco smoking in these populations, cannabis use should be considered where self-reported nonsmokers show high BCO.