The Effect of Pack Warning Labels on Quitting and Related Thoughts and Behaviors in a National Cohort of Aboriginal and Torres Strait Islander Smokers.

INTRODUCTION: The high prevalence of smoking among Aboriginal and Torres Strait Islander people in Australia (39%) contributes substantially to health inequalities. This study assesses the impact of warning labels on quitting and related thoughts and behaviors for Aboriginal and Torres Strait Islander smokers. METHODS: Participants were recruited from communities served by 34 Aboriginal Community Controlled Health Services and communities in the Torres Strait, Australia, using quota sampling. A cohort of 642 daily/weekly smokers completed relevant questions at baseline (April 2012-October 2013) and follow-up (August 2013-August 2014). RESULTS: We considered three baseline predictor variables: noticing warning labels, forgoing cigarettes due to warning labels ("forgoing") and perceiving labels to be effective. Forgoing increased significantly between surveys only for those first surveyed prior to the introduction of plain packs (19% vs. 34%); however, there were no significant interactions between forgoing cigarettes and the introduction of new and enlarged graphic warning labels on plain packaging in any model. Forgoing cigarettes predicted attempting to quit (adjusted odds ratio [AOR]: 1.45, 95% confidence interval [CI]: 1.02-2.06) and, among those who did not want to quit at baseline, wanting to quit at follow-up (AOR: 3.19, 95% CI: 1.06-9.63). Among those less worried about future health effects, all three variables predicted being very worried at follow-up. Often noticing warning labels predicted correct responses to questions about health effects that had featured on warning labels (AOR: 1.84, 95% CI: 1.20-2.82) but not for those not featured. CONCLUSIONS: Graphic warning labels appear to have a positive impact on the understanding, concerns and motivations of Aboriginal and Torres Strait Islander smokers and, through these, their quit attempts. IMPLICATIONS: Graphic warning labels are likely to be effective for Aboriginal and Torres Strait Islander smokers as they are for the broader Australian population.

Continuing to lift the burden: using a continuous quality improvement approach to advance Aboriginal tobacco resistance and control.

Smoking remains the most preventable cause of early mortality and ill health in Aboriginal people. The Aboriginal Health & Medical Research Council of New South Wales has developed the Aboriginal Tobacco Resistance and Control (ATRAC) Yarning Tool with a range of key stakeholders, to contribute to reducing the prevalence of smoking in Aboriginal communities. The Yarning Tool was adapted from the ATRAC Framework and aims to promote the meaningful discussion, planning and strengthening of tobacco resistance and control activities using a continuous quality improvement (CQI) approach. CQI provides an opportunity to closer align current health service practice with evidence. The Yarning Tool was piloted using focus group testing across four Aboriginal Community Controlled Health Services (ACCHSs) and three Local Health Districts. Purposive sampling was used to ensure that services engaged were from a diverse range of settings, with representation from metropolitan, regional and rural areas, and services with varying degrees of tobacco control capacity. Overall, feedback on the Yarning Tool and its potential use was positive. Pilot participants consistently reported that the Yarning Tool brought staff from a range of positions together to focus on tackling tobacco for the service and community. The pilot participants agreed that the Yarning Tool could be practical for the planning and reviewing stages of a CQI activity, and recommended that the tool should be completed every 6 months. The Yarning Tool is a simple tool to guide the ATRAC Framework principles into practice, and provides a platform to support Aboriginal community-led efforts, and coordination and integration of tobacco control efforts. The tool shows promise as a mechanism to encourage ACCHSs and other relevant services to use a CQI approach to reduce tobacco use in Aboriginal communities.

Lifting the burden: a coordinated approach to action on Aboriginal tobacco resistance and control in NSW.

Smoking prevalence continues to be significantly higher among Aboriginal people than non-Aboriginal people, resulting in a range of serious health consequences and inequities. The Aboriginal Health and Medical Research Council of New South Wales (AHandMRC) and the New South Wales (NSW) Ministry of Health (the Ministry) have worked in partnership to develop The ATRAC Framework: A Strategic Framework for Aboriginal Tobacco Resistance and Control in NSW, in collaboration with Aboriginal communities and a range of stakeholders. The goal of the ATRAC Framework is to reduce smoking prevalence and the harmful impacts of tobacco use among Aboriginal people and communities in NSW. The framework includes reviews of relevant evidence and recommended actions, organised under six areas: leadership, partnerships and coordination; community action, awareness and engagement; workforce development; supportive environments; quitting support; and evidence, evaluation and research. The framework stresses that, to be successful, Aboriginal tobacco resistance and control programs and activities need to be evidence based, coordinated, integrated and involve Aboriginal people and Aboriginal community controlled health organisations in all aspects, from development through to implementation and evaluation. Consultations and evidence reviews highlight the importance of workforce support and development, including the ongoing need for more workers specialising in Aboriginal tobacco resistance and control, as well as ongoing training for all staff involved in delivering care to Aboriginal people. Other key strategies identified in the framework include improving access to nicotine replacement therapy and other medications to support quitting; supporting, strengthening and building on existing innovative community-based programs; and further developing the evidence base. The AHandMRC and the Ministry will continue to work in partnership to drive the use of the ATRAC Framework by all people involved in Aboriginal tobacco resistance and control in NSW for resource allocation, planning, implementation and evaluation of existing and future activities.

Tobacco control policies and activities in Aboriginal community-controlled health services.

OBJECTIVES: To describe tobacco control policies and activities at a nationally representative sample of Aboriginal community-controlled health services (ACCHSs). DESIGN, SETTING AND PARTICIPANTS: The Talking About The Smokes (TATS) project used a quota sampling design to recruit 34 ACCHSs around Australia. Between April 2012 and October 2013, a representative at each ACCHS completed a survey about the service's tobacco control policies and activities. Questions about support for smoke-free policies were also included in the TATS project survey of 2435 Aboriginal and Torres Strait Islander members of the communities served by the ACCHSs. MAIN OUTCOME MEASURES: ACCHS tobacco control policies and activities. RESULTS: Thirty-two surveys were completed, covering 34 sites. Most ACCHSs (24/32) prioritised tobacco control "a great deal" or "a fair amount", and all services had smoke-free workplace policies. Most had staff working on tobacco control and had provided tobacco control training within the past year. A range of quit-smoking information and activities had been provided for clients and the community, as well as extra smoking cessation support for staff. There was strong support for smoke-free ACCHSs from within the Aboriginal communities, with 87% of non-smokers, 85% of ex-smokers and 77% of daily smokers supporting a complete ban on smoking inside and around ACCHS buildings. CONCLUSIONS: The high level of commitment and experience within ACCHSs provides a strong base to sustain further tobacco control measures to reduce the very high smoking prevalence in Aboriginal and Torres Strait Islander populations.

Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers.

OBJECTIVES: To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit. DESIGN, SETTING AND PARTICIPANTS: A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013. MAIN OUTCOME MEASURES: Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit. RESULTS: More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising. CONCLUSIONS: Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.