Health risk factors in Australian Stroke Survivors: A latent class analysis

ISSUES ADDRESSED

To (i) determine the prevalence of health risk factors (physical activity, diet, alcohol, smoking, blood pressure medication use and mental health) in community-dwelling stroke survivors; and (ii) examine how these health risk factors cluster, and identify associations with physical functioning, independent living, or sociodemographic factors.

METHODS

A secondary analysis of data obtained during a national randomised controlled trial. Participants had experienced stroke and completed a baseline telephone survey on demographic and stroke characteristics, health risk factors, physical functioning and independence in activities of daily living. A latent class analysis was performed to determine health risk profiles. Univariate logistic regressions were performed to identify if participant characteristics were associated with resulting classes.

RESULTS

Data analysed from 399 participants. Two classes of health risk factors were identified: Low Mood, Food & Moves Risk (16% of participants) and Alcohol Use Risk (84% of participants). The Low Mood, Food & Moves Risk group had poorer diet quality, lower physical activity levels and higher levels of depression and anxiety. Lower levels of independence and physical functioning were predictor variables for this group. In contrast, the Alcohol Use Risk group had better physical activity and diet scores, significantly lower probability of depression and anxiety, but a higher probability of risky drinking.

CONCLUSIONS

We identified two distinct health risk factor groups in our population. SO WHAT?: Future interventions may benefit from targeting the specific needs and requirements of people who have experienced stroke based on their distinct risk group. Alcohol consumption in poststroke populations requires further attention.

Outback Quit Pack: Feasibility trial of outreach smoking cessation for people in rural, regional, and remote Australia

BACKGROUND

Tobacco smoking rates are higher in rural, regional, and remote (RRR) areas in Australia, and strategies to improve access to quit supports are required. This pilot study examined the feasibility of a smoking cessation intervention for people in RRR areas who smoke with the intention of using this data to design a powered effectiveness trial.

METHODS

A randomised controlled trial (RCT) of the feasibility of a 12-week 'Outback Quit Pack' intervention consisting of mailout combination nicotine replacement therapy (NRT) and a proactive referral to Quitline, compared with a minimal support control (1-page smoking cessation support information mailout) was conducted between January and October 2021. Participants recruited via mailed invitation or Facebook advertising, were adults who smoked tobacco (≥10 cigarettes/day) and resided in RRR areas of New South Wales, Australia. Participants completed baseline and 12-week follow-up telephone surveys. Outcomes were feasibility of trial procedures (recruitment method; retention; biochemical verification) and acceptability of intervention (engagement with Quitline; uptake and use of NRT).

RESULTS

Facebook advertising accounted for 97% of participant expressions of interest in the study (N = 100). Retention was similarly high among intervention (39/51) and control (36/49) participants. The intervention was highly acceptable: 80% of the intervention group had ≥1 completed call with Quitline, whilst Quitline made 3.7 outbound calls/participant (mean 14:05 mins duration). Most of the intervention group requested NRT refills (78%). No differences between groups in self-reported cessation outcomes. Biochemical verification using expired air breath testing was not feasible in this study.

CONCLUSION

The Outback Quit Pack intervention was feasible and acceptable. Alternative methods for remote biochemical verification need further study. SO WHAT?: A powered RCT to test the effectiveness of the intervention to improve access to evidence-based smoking cessation support to people residing in RRR areas is warranted.

Perspectives on limiting tobacco access and supporting access to nicotine vaping products among clients of residential drug and alcohol treatment services in Australia

INTRODUCTION

Tobacco endgame strategies aim to drive down population smoking rates, the success of which can be improved with public buy-in, including from populations with high smoking rates such as alcohol and other drug (AOD) service clients. This study aimed to explore acceptability of tobacco retail and nicotine reduction, and subsidised nicotine vaping to support AOD service clients following a smoking cessation attempt.

METHODS

We interviewed 31 Australian AOD service clients who currently or previously smoked, following a 12-week randomised trial comparing nicotine replacement therapy with nicotine vaping product (NVP) for smoking cessation. Participants were asked how effectively three scenarios would support tobacco cessation: tobacco retailer reduction, very low-nicotine cigarette standard and subsidised NVP access. We thematically analysed participant views on how each approach would support tobacco abstinence.

RESULTS

Tobacco retailer reduction raised concerns about increasing travel and accessing cigarettes from alternate sources, with generally lower acceptability, though a range of perspectives were provided. Reducing nicotine in tobacco products was described as reducing appeal of smoking and potentially increasing illicit purchases of non-reduced nicotine products. Clients of AOD services were highly accepting of subsidised NVP access for tobacco cessation, as this would partly address financial and socioeconomic barriers.

CONCLUSIONS

Australian tobacco control policy should consider how these approaches impact ease and likelihood of tobacco access by AOD service clients in relation to the general population. Understanding clients' acceptability of tobacco control and endgame measures can inform how to avoid potential unintended consequences for these clients.

Smoking Cessation Interventions and Abstinence Outcomes for People Living in Rural, Regional, and Remote Areas of Three High-Income Countries: A Systematic Review

INTRODUCTION

Tobacco smoking rates in high-income countries are greater in rural, regional, and remote (RRR) areas compared to cities. Yet, there is limited knowledge about interventions targeted to RRR smokers. This review describes the effectiveness of smoking cessation interventions for RRR smokers in supporting smoking abstinence.

AIMS AND METHODS

Seven academic databases were searched (inception-June 2022) for smoking cessation intervention studies to include if they reported on RRR residents of Australia, Canada, or the United States, and short- (<6 months) or long-term (≥6 months) smoking abstinence outcomes. Two researchers assessed study quality, and narratively summarized findings.

RESULTS

Included studies (n = 26) were primarily randomized control (12) or pre-post (7) designs, from the United States (16) or Australia (8). Five systems change interventions were included. Interventions included cessation education or brief advice, and few included nicotine monotherapies, cessation counseling, motivational interviewing, or cognitive behavioral therapy. Interventions had limited short-term effects on RRR smoking abstinence, decreasing markedly beyond 6 months. Short-term abstinence was best supported by contingency, incentive, and online cessation interventions, and long-term abstinence by pharmacotherapy.

CONCLUSIONS

Cessation interventions for RRR smokers should include pharmacotherapy and psychological cessation counseling to establish short-term abstinence, and identify effective means of maintaining abstinence beyond 6 months. Contingency designs are a suitable vehicle for psychological and pharmacotherapy support for RRR people who smoke, and intervention tailoring should be explicitly considered.

IMPLICATIONS

Smoking disproportionately harms RRR residents, who can encounter access barriers to smoking cessation support. High-quality intervention evidence and outcome standardization are still required to support long-term RRR smoking abstinence.

A pilot randomised controlled trial of abrupt versus gradual smoking cessation in combination with vaporised nicotine products for people receiving alcohol and other drug treatment

BACKGROUND

Vaporised nicotine products (VNPs) may be a potential quit smoking strategy. Most research has permitted participants to use VNPs ad libitum. This is the first study to examine combining the use of a VNP with a gradual or abrupt cessation guideline. This study aims to test the potential feasibility of a quit smoking strategy (abrupt verses gradual cessation) in combination with vaporised nicotine products among people in AOD treatment.

METHODS

We conducted a pilot randomised controlled trial between April 2018 and July 2019. Participants were recruited from AOD programs located within one area health service in Australia. Participants were provided with two VNPs, a 12-week supply of nicotine e-liquid and randomised to either the abrupt (assigned a quit date the day they were provided their VNP) or gradual quit smoking strategy (reduce baseline number of cigarettes per day by 25% over a 4 week period), no further behavioral support was provided. Feasibility was assessed through successful recruitment rates, retention, and adherence to study conditions. Participant perceived helpfulness and satisfaction assessed acceptability.

RESULTS

Among 80 interested individuals, 66 were eligible and consented (100% recruitment rate). From the 66 participants that consented and completed the baseline survey, 60 received the intervention assigned at a 1:1 ratio with 30 in the gradual cessation and 30 in the abrupt cessation group. Retention was 86.4% (n = 52) at 12-weeks post-intervention commencement. Ninety-six percent (n = 25) of participants in the gradual and 95.8% (n = 23) of participants in the abrupt group were using the VNPs at 12-weeks (p = 0.66). There was no difference in adherence to the assigned quit plan between gradual cessation 44% (n = 11) and abrupt cessation 71% (n = 17) groups (p = 0.117). Median perceived helpfulness of VNPs was high for both gradual (10/10) and abrupt (9/10) groups (p = 0.813). Similarly, median perceived satisfaction of VNPs was high for both gradual (9 /10) and abrupt (8/10) groups (p = 0.414).

CONCLUSIONS

AOD participants found an intervention that involved VNPs to be satisfying and helpful. Future large scale trials are needed to elucidate whether a gradual or abrupt cessation guideline is more beneficial in main a quit attempt with a VNP.

Evaluation of an online intervention for improving stroke survivors' health-related quality of life: A randomised controlled trial

BACKGROUND

The aim of this trial was to evaluate the effectiveness of an online health behaviour change intervention-Prevent 2nd Stroke (P2S)-at improving health-related quality of life (HRQoL) amongst stroke survivors at 6 months of follow-up.

METHODS AND FINDINGS

A prospective, blinded-endpoint randomised controlled trial, with stroke survivors as the unit of randomisation, was conducted between March 2018 and November 2019. Adult stroke survivors between 6 and 36 months post-stroke with capacity to use the intervention (determined by a score of ≥4 on the Modified Rankin Scale) and who had access and willingness to use the internet were recruited via mail-out invitations from 1 national and 1 regional stroke registry. Participants completed baseline (n = 399) and 6-month follow-up (n = 356; 89%) outcome assessments via computer-assisted telephone interviewing (CATI). At baseline the sample had an average age of 66 years (SD 12), and 65% were male. Randomisation occurred at the end of the baseline survey; CATI assessors and independent statisticians were blind to group allocation. The intervention group received remote access for a 12-week period to the online-only P2S program (n = 199; n = 28 lost at follow-up). The control group were emailed and posted a list of internet addresses of generic health websites (n = 200; n = 15 lost at follow-up). The primary outcome was HRQoL as measured by the EuroQol Visual Analogue Scale (EQ-VAS; self-rated global health); the outcome was assessed for differences between treatment groups at follow-up, adjusting for baseline measures. Secondary outcomes were HRQoL as measured by the EQ-5D (descriptive health state), diet quality, physical activity, alcohol consumption, smoking status, mood, physical functioning, and independent living. All outcomes included the variable 'stroke event (stroke/transient ischaemic attack/other)' as a covariate, and analysis was intention-to-treat. At 6 months, median EQ-VAS HRQoL score was significantly higher in the intervention group than the control group (85 vs 80, difference 5, 95% CI 0.79-9.21, p = 0.020). The results were robust to the assumption the data were missing at random; however, the results were not robust to the assumption that the difference in HRQoL between those with complete versus missing data was at least 3 points. Significantly higher proportions of people in the intervention group reported no problems with personal care (OR 2.17, 95% CI 1.05-4.48, p = 0.0359) and usual activities (OR 1.66, 95% CI 1.06-2.60, p = 0.0256) than in the control group. There were no significant differences between groups on all other secondary outcomes. The main limitation of the study is that the sample comprises mostly 'well' stroke survivors with limited to no disability.

CONCLUSIONS

The P2S online healthy lifestyle program improved stroke survivors' self-reported global ratings of HRQoL (as measured by EQ-VAS) at 6-month follow-up. Online platforms represent a promising tool to engage and support some stroke survivors.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617001205325.

Barriers and facilitators to using vaporised nicotine products as smoking cessation aids among people receiving treatment for substance use disorder

INTRODUCTION

Vaporised nicotine products (VNPs) may be useful smoking cessation aids for people in alcohol and other drug (AOD) treatment, a population with high tobacco-related morbidity and mortality rates. This qualitative study aimed to examine the barriers and facilitators of using VNPs as part of a clinical trial to reduce or quit smoking among people in AOD treatment.

METHODS

Thirteen people in AOD treatment who were participating in a trial of VNPs for smoking cessation (QuitENDs) completed a brief semi-structured interview examining experiences of using VNPs to reduce or quit smoking. Transcribed data was analysed using the iterative categorisation framework.

RESULTS

Many participants expressed the benefit of having a smoking cessation aid that addressed nicotine cravings and the behavioural hand-to-mouth action to help them reduce or quit smoking. Although many participants reported that VNPs were easy to use, some found maintaining the device to be challenging. Some participants described Australian regulations limiting use of VNPs as reducing their desire to use the device as a cessation aid. Many participants attempting to reduce or quit tobacco and cannabis simultaneously stated that VNPs alone were insufficient to help them reduce or quit tobacco.

CONCLUSIONS

VNPs hold significant promise as smoking cessation aids among people in AOD treatment because of their unique ability to satisfy both nicotine cravings and behavioural habits. However, multiple barriers, such as accessibility, maintenance, and the challenges of reducing other substance use simultaneously also need to be addressed for optimal engagement in clinical trials with VNPs to quit smoking.

Access to and use of internet and social media by low-morbidity stroke survivors participating in a national online secondary prevention trial: A cross-sectional survey (Preprint)

Background

eHealth applications for stroke are a growing area of research that has yielded promising results. However, little is known about how stroke survivors engage with the internet, social media, and other digital technologies on a day-to-day basis.

Objective

This study had three main objectives: to describe the type, frequency, and purpose of technology use among a cohort of low-morbidity stroke survivors; to investigate associations between social media use and participant factors, including sociodemographics, physical function, and independence in activities of daily living; and to investigate associations between stroke-related health risk factors and the use of the internet to search for health and medical information.

Methods

This study is a secondary analysis of data obtained during a national randomized controlled trial—Prevent 2^nd Stroke. The participants were stroke survivors recruited from 2 Australian stroke registries who completed 2 telephone-administered surveys to collect data on demographics and stroke characteristics; health risk factors (diet quality, physical activity, blood pressure medication, alcohol intake, anxiety and depression, and smoking status); physical functioning; independence in activities of daily living; and questions about what technology they had access to, how often they used it, and for what purposes. Participants were eligible if they had no more than a moderate level of disability (modified Rankin score ≤3) and had access to the internet. Multivariable logistic regression was used to assess the associations between social media use and sociodemographics, physical function, and independence in activities of daily living as well as associations between stroke-related health risk factors and the use of the internet to search for health and medical information.

Results

Data from 354 participants were included in the analysis. Approximately 79.1% (280/354) of participants used the internet at least daily, 40.8% (118/289) accessed social media on their phone or tablet daily, and 46.4% (134/289) looked up health and medical information at least monthly. Women were 2.7 times more likely to use social media (adjusted odds ratio 2.65, 95% CI 1.51-4.72), and people aged >75 years were significantly less likely to use social media compared with those aged <55 years (adjusted odds ratio 0.17, 95% CI 0.07-0.44). Health risk factors were not found to be associated with searching for health- or medical-related information.

Conclusions

The internet appears to be a viable platform to engage with stroke survivors who may not be high-morbidity to conduct research and provide information and health interventions. This is important given that they are at high risk of recurrent stroke regardless of their level of disability. Exploring the technology use behaviors and the possibility of eHealth among survivors who experience higher levels of morbidity or disability because of their stroke is an area of research that warrants further study.

Patterns and predictors of nicotine replacement therapy use among alcohol and other drug clients enrolled in a smoking cessation randomised controlled trial

INTRODUCTION

Nicotine replacement therapy (NRT) use to support client smoking quit attempts is low and inconsistent at alcohol and other drug (AOD) treatment services. This study examined predictors of any NRT use and combination NRT use among AOD clients who were smokers.

METHODS

The study was part of a cluster-RCT of an organisational change intervention to introduce smoking cessation support as part of routine treatment in 32 AOD services. The intervention provided AOD services with free NRT and training. Service clients completed baseline (n = 896), 8-week (n = 471) and 6.5-month (n = 427) follow-up surveys. Mixed-model logistic regression examined whether baseline socio-demographic and smoking variables were associated with single and combination NRT use.

RESULTS

At 8-weeks follow-up 57% (n = 269/471), and at 6.5-months 33% (n = 143/427) of participants reported using at least one form of NRT. Odds of NRT use at 8-weeks follow-up were greater among participants from treatment vs control group (OR = 3.69, 95%CI 1.8-7.4; p < 0.001), higher vs lower nicotine dependence (OR = 1.74 95%CI 1.1-2.8; p = 0.024), or those motivated to quit (OR = 1.18 95%CI 1.0-1.4; p = 0.017). At 6.5-months, only the treatment arm remained significant. Combination NRT use at the 8-week follow-up was higher among those in treatment vs control group (OR = 2.75 95%CI 1.4-5.6; p = 0.005), or with higher vs lower nicotine dependence (OR = 2.12 95%CI 1.2-3.8; p = 0.014). No factors were associated with combination NRT use at 6.5-months.

CONCLUSIONS

An organisational change intervention that supplied AOD services with NRT training and products to provide to clients during treatment significantly increases client single form and combination NRT use in the short term.

QuitNic: A Pilot Randomized Controlled Trial Comparing Nicotine Vaping Products With Nicotine Replacement Therapy for Smoking Cessation Following Residential Detoxification

Introduction

The QuitNic pilot trial aimed to test the feasibility of providing a nicotine vaping product (NVP) compared with combination nicotine replacement therapy (NRT) to smokers upon discharge from a smoke-free residential substance use disorder (SUD) treatment service.

Methods

QuitNic was a pragmatic two-arm randomized controlled trial. At discharge from residential withdrawal, 100 clients received telephone Quitline behavioral support and either 12-week supply of NRT or an NVP. Treatment adherence and acceptability, self-reported abstinence, cigarettes smoked per day (CPD), frequency of cravings, and severity of withdrawal symptoms were assessed at 6 and 12 weeks. Results are reported for complete cases and for abstinence outcomes, penalized imputation results are reported where missing is assumed smoking.

Results

Retention on was 63% at 6 weeks and 50% at 12 weeks. At 12 weeks, 68% of the NRT group reported using combination NRT while 96% of the NVP group used the device. Acceptability ratings for the products were high in both groups. At 12 weeks, 14% of the NVP group and 18% of the NRT group reported not smoking at all in the last 7 days. Mean CPD among continued smokers decreased significantly between baseline to 12 weeks in both groups; from 19.91 to 4.72 for the NVP group (p < .001) and from 20.88 to 5.52 in the NRT group (p < .001). Cravings and withdrawal symptoms significantly decreased for both groups.

Conclusions

Clients completing residential withdrawal readily engaged with smoking cessation post-treatment when given the opportunity. Further research is required to identify the most effective treatments postwithdrawal for this population at elevated risk of tobacco-related harm.

Trial registration number

ACTRN12617000849392

Implications

This pilot study showed that smoking cessation support involving options for nicotine replacement and Quitline-delivered cognitive behavioral counseling is attractive to people after they have been discharged from SUD treatment. Both nicotine vaping products and nicotine replacement therapies were highly acceptable and used by participants who reported reductions in cravings for cigarettes and perceptions of withdrawal symptoms and reductions in number of cigarettes smoked. Some participants self-reported abstinence from cigarettes—around one in five reported having quit smoking cigarettes at 12 weeks postdischarge. The results have significant public health implications for providing quit support following discharge from SUD treatment.

Alcohol and other drug health-care providers and their client's perceptions of e-cigarette use, safety and harm reduction

INTRODUCTION

E-cigarettes containing nicotine may potentially assist cessation in a heavily nicotine-dependent population with high relapse and tobacco-related burden. This study aims to determine alcohol and other drug (AOD) health-care provider and client awareness, use and attitudes regarding harm reduction and safety of e-cigarettes.

METHODS

The study was part of a larger cluster randomised controlled trial with 32 Australian AOD services. At a post-intervention survey conducted October 2016, health-care providers were asked whether they believed e-cigarettes could help smokers quit tobacco, whether they believe e-cigarettes are safer than tobacco smoking and whether they would recommend e-cigarettes to clients who are interested in quitting smoking. At the 6-month follow-up survey conducted January 2015-March 2016, AOD clients were asked about their e-cigarette knowledge, ever use, current use, reasons for use and place of purchase.

RESULTS

One hundred and eighty health-care providers and 427 AOD clients responded. A minority of health-care providers agreed with the statements that e-cigarettes could help smokers quit tobacco (30%), while just under one-third (25%) agreed that e-cigarettes were safer than tobacco smoking. However, only 19% would recommend e-cigarettes. Most AOD clients (93%) reported awareness of e-cigarettes, 39% reported ever use; however, only 7% reported current use. Of those reporting ever use, 52% used a nicotine e-cigarette. The most common reasons for e-cigarette use were 'wanted to try' (72%) and 'help cut down smoking' (70%).

DISCUSSION AND CONCLUSIONS

Both AOD health-care providers and clients are aware of e-cigarettes but are cautious in using and recommending their use.

Effect of increasing the delivery of smoking cessation care in alcohol and other drug treatment centres: a cluster-randomized controlled trial

AIM

Aims were to test the effectiveness of an organizational change intervention integrating smoking cessation treatment into usual alcohol and other drug (AOD) treatment, compared with usual care, on (1) 7-day point prevalence abstinence (PPA) at 8 weeks follow-up; (2) prolonged abstinence; (3) cigarettes smoked per day; (4) number of quit attempts; and (5) offer and use of nicotine replacement therapy (NRT). All outcomes were assessed at 8 weeks and 6.5 months follow-up.

DESIGN

Cluster-randomized controlled trial, with AOD service as unit of randomization, conducted January 2015-March 2016.

SETTING

Thirty-two eligible services (provided face-to-face client sessions to ≥ 50 clients/year) in Australia were randomized to control (usual care; n = 15) or intervention (n = 17) groups by an independent blinded biostatistician.

PARTICIPANTS

Eligible participants (≥ 16 years, current smoker) completed surveys at the service at baseline (n = 896) and telephone follow-up surveys (conducted by blinded assessors) at 8 weeks (n = 471; 53%) and 6.5 months (n = 427; 48%).

INTERVENTION

Intervention services received an intervention to establish routine screening, assessment and delivery of smoking cessation care.

MEASUREMENTS

Primary outcome was biochemically verified 7-day PPA at 8-week follow-up. Secondary outcomes included verified and self-reported prolonged abstinence, self-reported 7-day PPA, cigarettes/day, quit attempts and offer and use of NRT. Intention-to-treat analyses were performed, assuming missing participants were not abstinent.

FINDINGS

At 8 weeks, the findings in verified 7-day PPA between groups [2.6 versus 1.8%, odds ratio (OR) = 1.72, 95% confidence interval (CI) = 0.5-5.7, P = 0.373] were inconclusive as to whether a difference was present. Significantly lower mean cigarettes/day were reported in the intervention group compared to the usual care group at 8 weeks [incidence rate ratio (IRR) = 0.88, 95% CI = 0.8-0.95, P = 0.001] but were similar at 6.5 months (IRR = 0.96, 95% CI = 0.9-1.02, P = 0.240) follow-up. At both follow-ups the intervention group reported higher rates of NRT use.

CONCLUSIONS

Integrating smoking cessation treatment into addiction services did not significantly improve short-term abstinence from smoking.

Same same but different: A comparison of LGB and non-LGB client preferences and reported receipt of smoking care in alcohol and other drug treatment services

INTRODUCTION AND AIMS

Lesbian, gay, and bisexual (LGB) people are more likely to use tobacco and other substances than non-LGB people. A limited body of research has examined LGB people in the alcohol and other drug (AOD) treatment setting. This study aims to examine the tobacco smoking behaviours of LGB people receiving AOD treatment, their receipt and preferences for quit support compared to non-LGB, as well as the factors associated with receipt of quit smoking support strategies for LGB people.

DESIGN AND METHODS

We examined baseline survey responses (February to August 2014) from a longitudinal RCT, with clients who were current smokers from 32 AOD treatment services in four states and territories of Australia.

RESULTS

Among 896 respondents, 100 respondents identified as LGB. Nearly all LGB (94%) respondents identifies as daily tobacco smokers. On average, LGB respondents had made more quit attempts in the last 12 months (3 vs 2, p = 0.012). Both LGB and non-LGB respondents reported receiving similar rates of quit smoking support however more LGB respondents reported receiving a prescription of varenicline (31.5% vs 36.4%, p = 0.04). Higher motivation to quit (OR 1.39 95% CI 1.07, 1.78) and older age of LGB respondents were associated with greater receipt of quit smoking support. Both LGB and non-LGB respondents reported similar preferences for quit support.

DISCUSSION AND CONCLUSIONS

LGB smokers in AOD treatment are attempting to quit smoking yet both LGB and non-LGB smokers are not receiving adequate treatment despite openness to receive multiple types of quit support.

Electronic cigarettes: Ever use, current use and attitudes among alcohol and other drug clients

INTRODUCTION AND AIMS

Electronic cigarettes (e-cigarettes) are becoming popular and may be a potential harm reduction and quit smoking aid for people who use other drugs. Data on e-cigarette use and perceptions among people who use drugs is limited. The current study examines tobacco smoking status, use and attitudes towards e-cigarettes among people in drug and alcohol treatment.

DESIGN AND METHODS

Data were collected through a standardised Patient Experience Tracking System device installed in the waiting room of six drug and alcohol clinical service programs located within one area health service in New South Wales, Australia during April to June 2017. Participants were clients of participating services aged 18 years and older.

RESULTS

Five hundred and eleven participants completed the survey, 85% were current smokers, 9% were ex-smokers and 6% were non-smokers. Over half of all participants (53%) had tried e-cigarettes in their lifetime, 26% reported current use and 77% of those were using them with nicotine. Just less than half of all participants believed that e-cigarettes were helpful for quitting or cutting down smoking tobacco cigarettes (48%). More than half of all respondents (59%) believed that tobacco cigarettes were more harmful than e-cigarettes (59%) and believed that e-cigarettes were an acceptable quit smoking aid for patients of drug and alcohol services (64%).

DISCUSSION AND CONCLUSIONS

Most participants were current tobacco smokers and had tried an e-cigarette though a minority were currently using e-cigarettes. Participant attitudes were favourable towards the use of e-cigarettes as quit smoking aids.

A cross sectional survey of internet use among a highly socially disadvantaged population of tobacco smokers

Background

Tobacco smoking is highest among population groups which are the most socially disadvantaged. Internet-based smoking cessation programs have been found to be effective, though rates of internet access are not well known in these groups. This study describes the rates of internet use and types of technology used to access the internet by a population of socially disadvantaged smokers. The study also examined relationships between sociodemographic and smoking behaviours with amount of internet use and type of device used.

Methods

A cross-sectional survey of 369 clients (response rate 77%) from two non-government community service organisations in metropolitan New South Wales, Australia was conducted using touchscreen computers. Descriptive statistics and logistic regressions were used to examine results.

Results

Eligible participants ranged from 19 to 88 years old current tobacco users. Over half (58%) of the participants reported weekly or more frequent use of the internet with less than a third (28%) not having any access. The odds of using the internet at least weekly decreased with age and as heaviness of smoking increased (OR = 0.94, p < 0.001; OR = 0.81, p = 0.022, respectively). Odds of internet use were higher as income increased (OR = 2.74, p < 0.001 for individuals earning $201–$400 per week; OR = 2.83, p = 0.006 for individuals earning > $400 per week). Device use differed for age and income.

Conclusions

Internet-based interventions appear to reach the majority of socially disadvantaged populations. It is expected that this reach will continue to grow, making internet-based interventions a potential platform for providing care to low socioeconomic individuals who smoke, however inequalities may be exacerbated for those individual without internet access.

Implications

Internet use among socially disadvantaged tobacco users is moderate (58%). An internet-based smoking cessation intervention for socially disadvantaged tobacco users may be an effective intervention however, older, heavier tobacco users may not benefit as easily due to limited internet access and therefore acknowledging these limitations when developing an intervention can help to acknowledge limitation of intervention reach.

An online intervention for improving stroke survivors' health-related quality of life: study protocol for a randomised controlled trial

Background

Recurrent stroke is a major contributor to stroke-related disability and costs. Improving health-risk behaviours and mental health has the potential to significantly improve recovery, enhance health-related quality of life (HRQoL), independent living, and lower the risk of recurrent stroke. The primary aim will be to test the effectiveness of an online intervention to improve HRQoL among stroke survivors at 6 months’ follow-up. Programme effectiveness on four health behaviours, anxiety and depression, cost-effectiveness, and impact on other hospital admissions will also be assessed.

Methods/design

An open-label randomised controlled trial is planned. A total of 530 adults will be recruited across one national and one regional stroke registry and block randomised to the intervention or minimal care control group. The intervention group will receive access to the online programme Prevent 2nd Stroke (P2S); the minimal care control group will receive an email with Internet addresses of generic health sites designed for the general population. The primary outcome, HRQoL, will be measured using the EuroQol-5D. A full analysis plan will compare between groups from baseline to follow-up.

Discussion

A low-cost per user option to supplement current care, such as P2S, has the potential to increase HRQoL for stroke survivors, and reduce the risk of second stroke.

Trial registration

Australian and New Zealand Clinical Trials Registry, ID: ACTRN12617001205325p. Registered on 17 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3604-0) contains supplementary material, which is available to authorized users.

Integrating Smoking Cessation Care into a Medically Supervised Injecting Facility Using an Organizational Change Intervention: A Qualitative Study of Staff and Client Views

Background: Clients accessing supervised injecting facilities (SIFs) smoke at high rates. An SIF piloted an organizational change intervention to integrate smoking cessation care as routine treatment. This study aims to explore staff acceptability, perceived facilitators, and perceived barriers to implementing six core components of an organizational change intervention to integrate smoking cessation care in an SIF. Staff and client views on the acceptability, facilitators, and barriers to the provision of smoking cessation care were also examined. Methods: This paper presents findings from the qualitative component conducted post-intervention implementation. Face-to-face semi-structured staff interviews (n = 14) and two client focus groups (n = 5 and n = 4) were conducted between September and October 2016. Recruitment continued until data saturation was reached. Thematic analysis was employed to synthesise and combine respondent views and identify key themes. Results: Staff viewed the organizational change intervention as acceptable. Commitment from leadership, a designated champion, access to resources, and the congruence between the change and the facility’s ethos were important facilitators of organizational change. Less engaged staff was the sole barrier to the intervention. Smoking cessation care was deemed suitable. Key facilitators of smoking cessation care included: Written protocols, ongoing training, and visually engaging information. Key barriers of smoking cessation care included: Lack of access to nicotine replacement therapy (NRT) outside of business hours, practical limitations of the database, and concerns about sustainability of NRT. Conclusion: This study develops our understanding of factors influencing the implementation of an organisational change intervention to promote sustainable provision of smoking cessation care in the SIF setting.

Australian university smoke-free policy implementation: a staff and student survey

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Integrating smoking cessation care in alcohol and other drug treatment settings using an organizational change intervention: a systematic review

BACKGROUND AND AIMS

Organizational change interventions involve systems and cultural change within health-care services to make smoking cessation care delivery part of usual treatment. Six strategies for organizational change have been proposed. This study examined the evidence for organizational change interventions in the alcohol and other drug (AOD) setting on: (a) smoking cessation care; and (b) smoking cessation and cessation-related outcomes.

METHODS

A systematic review with narrative synthesis was conducted. MEDLINE, PsycINFO, CINAHL, EMBASE and Scopus were searched using keywords and MeSH terms from database inception to 1 June 2018. Interventions were assessed against the six organizational change strategies.

RESULTS

Of the 5155 papers identified, 14 publications from seven unique studies were included. Most studies employed four or fewer organizational change strategies. The majority (n = 11) were rated weak to moderate in methodological quality. Nine published papers, four unique studies, examined staff reported provision of smoking cessation care; eight reported an increase, one found no change. Three papers, two unique studies, examined client receipt of care; all found significant increases. Three papers, two unique studies, assessed staff smoking prevalence from pre- to post-intervention. Only one study reported a significant reduction in staff smoking prevalence (35.2 versus 21.8%, P = 0.005). Nine papers, six unique studies, assessed client smoking cessation and smoking-related outcomes. Seven papers reported on client smoking prevalence; two found a significant decrease and five found no change to smoking. Four papers reported on number of cigarettes per day, three found a significant decrease and one found no change. Two papers reported on smoking cessation finding a 10% and a 25% seven-day point prevalence abstinence post-discharge from the AOD service.

CONCLUSIONS

Organizational change interventions within health-care services to make smoking cessation care delivery part of usual treatment offer promise for increasing smoking cessation care and reducing smoking prevalence.

Integrating smoking cessation care into routine service delivery in a medically supervised injecting facility: An acceptability study

BACKGROUND

Among people who inject drugs (PWIDs) the prevalence of tobacco smoking exceeds 80%; making smoking cessation intervention a priority for this population. This study aims to examine staff and client perspectives from a supervised injecting facility regarding: i) whether an organizational change intervention increased rates of smoking cessation care delivery (pre- to post-intervention); and ii) acceptability of the intervention.

METHODS

A pre-and-post intervention pilot study in a supervised injecting facility was conducted in Sydney, Australia between July 2014-December 2015. The intervention employed an organizational change approach and included six components. Cross-sectional samples of staff (pre n = 27, post n = 22) and clients (pre n = 202, post n = 202) completed online surveys pre and post intervention.

RESULTS

From pre to post-intervention staff reported smoking cessation practices significantly increased for the provision of verbal advice (30% to 82%; p < 0.001), offer of free or subsidized nicotine replacement therapy (30% to 91%; p < 0.001), referral to a general practitioner (19% to 64%; p = 0.001), and follow-up to check on quit smoking progress (18.5% to 64%; p = 0.001). Significantly more clients reported receiving all smoking cessation strategies post-intervention. Over 85% of staff agreed that it was acceptable to address client smoking as part of usual care and 95% of clients agreed that it was acceptable to be asked by staff about their tobacco smoking.

CONCLUSIONS

Increasing the provision of smoking cessation care using an organizational change approach is both feasible for staff and acceptable to staff and clients of supervised injecting facilities.

Electronic nicotine devices to aid smoking cessation by alcohol- and drug-dependent clients: protocol for a pilot randomised controlled trial

Background

Up to 95% of people entering treatment for use of alcohol or other drugs (AOD) smoke tobacco. Smokers receiving treatment for AOD use are interested in quitting and make quit attempts, but relapse is more common and rapid compared with the general population of smokers. New ways to address smoking in this population are needed. Electronic nicotine devices (ENDs) or electronic cigarettes hold significant potential as both cessation aids and harm reduction support. This study focuses on the potential of ENDs to facilitate smoking cessation and to sustain it in the medium term among people in treatment for AOD use. The aim of this trial is to explore the effectiveness, feasibility and acceptability of ENDs for smoking cessation compared with combination nicotine replacement therapy (NRT) for clients after discharge from a smoke-free AOD residential withdrawal service.

Methods/design

The study is a pragmatic randomised controlled trial. In total, 100 participants will be recruited following admission to a smoke-free residential withdrawal service in Melbourne, Australia. Participants will complete a baseline survey and be randomised to either the END group (n = 50) or the NRT group (n = 50) prior to discharge. Both groups will receive telephone counselling support from quitline. Follow-up measures will be assessed at 6 and 12 weeks following discharge. The primary outcome is continuous abstinence from smoking at 12 weeks post discharge. Secondary outcomes include: 7-day point prevalence from smoking, point prevalence abstinence from all nicotine (including NRT and ENDs), cravings and withdrawal, time to relapse, and treatment adherence (use of NRT, ENDs and quitline).

Discussion

This is the first randomised controlled trial to assess the effectiveness and acceptability of ENDs within a population dependent on AOD, a priority group with very high levels of smoking. The research will test a model of how to incorporate novel smoking cessation support into a period of high treatment receptiveness.

Trial registration

Australian New Zealand Clinical Trial Registry, ACTRN12617000849392. Registered on 8 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2786-1) contains supplementary material, which is available to authorized users.

Signs, Fines and Compliance Officers: A Systematic Review of Strategies for Enforcing Smoke-Free Policy

Background. Smoke-free environment policies limit or eliminate the use of smoke-producing tobacco in designated areas thereby reducing second hand smoke. Enforcement is perceived as critical to the successful adoption of a smoke-free policy. However, there is limited guidance available regarding effective enforcement strategies. A systematic review was conducted to examine the effectiveness of enforcement strategies at increasing compliance with and enforcement of smoke-free policies; and to determine circumstances other than enforcement strategies that are associated with compliance with smoke-free policies. Design. Medline, Medline in Process, The Cochrane Library, Embase, PsycInfo and CINAHL databases were searched using MeSH and keywords for relevant studies published between January 1980 and August 2017. A narrative synthesis and methodological quality assessment of included studies was undertaken. Results. Policy promotion and awareness-raising activities, signage, enforcement officers, and penalties for violations were the enforcement strategies most frequently cited as being associated with successful policy enforcement. Additionally, awareness of the laws, non-smoking management and lower staff smoking rates, and membership of a network guiding the policy enforcement contributed to higher compliance with smoke-free policies. Conclusions. There is weak evidence of the effectiveness of strategies associated with compliance with smoke-free policies. Given the evidence base is weak, well-designed trials utilizing appropriate evaluation designs are needed. Overall enforcement strategies associated with total smoke-free bans resulted in higher levels of compliance than strategies for policies that had only partial smoke-free bans.

Prevent 2nd Stroke: a pilot study of an online secondary prevention program for stroke survivors

OBJECTIVE

The prevalence of modifiable health risk factors and psychological distress following a stroke is high and markedly increase the chance of a second stroke. This study aimed to examine the usability and acceptability of an online secondary prevention program addressing modifiable psycho-behavioural risk factors for stroke survivors.

METHODS

A pre-post pilot study was conducted in Australia between 2016 and 2017. Participants were recruited through the Australian Stroke Clinical Registry and completed measures of health-related quality of life, physical activity, smoking status, depression and anxiety, alcohol status, nutrition and internet use. Participants also used an online secondary prevention program (Prevent 2^nd Stroke) over a two-week period. At follow-up, acceptability and usability of the program were assessed.

RESULTS

A total of 18 out of 19 participants reported engaging in multiple health risk behaviours. Participants reported that they were interested in receiving an online program that provided health information (73.7%). Participants indicated Prevent 2^nd Stroke was easy to use (63.1%) and that they would recommend the program to other stroke survivors (63.1%).

CONCLUSIONS

The results indicated that online programs are an acceptable way to address these health outcomes. Implications to public health: Further research is needed to assess the effectiveness of these interventions using powered trials.

The unmet needs of informal carers of stroke survivors: a protocol for a systematic review of quantitative and qualitative studies

INTRODUCTION

Stroke events deeply affect not only the stroke survivor but also often the quality of life and physical and psychological health of the family and friends who care for them. There is a need for further information about the unmet needs of these informal carers in order to develop support services and interventions. The primary objective of this review is to report and synthesise the research describing the unmet needs of carers of stroke survivors.

METHODS AND ANALYSIS

A systematic review of quantitative and qualitative studies that report on the unmet needs of carers will be conducted. The following databases will be searched for relevant articles: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Allied and Complementary Medicine Database and Scopus. No publication date constraints will be applied. Studies will be limited to those published in English and conducted among humans. Eligible studies will report on the unmet needs of informal carers of stroke survivors, defined as family members, friends and other unpaid caregivers. Studies which focus on formal, clinical or medical caregivers will be excluded. A narrative synthesis and pooled analysis of the main outcomes will be reported.

ETHICS AND DISSEMINATION

This review will be submitted to a peer-reviewed journal. Our findings are expected to provide new insights into the unmet needs of stroke survivors' carers. Knowledge about the unmet needs of carers will inform the development and refinement of interventions and services to address these needs and better support carers of stroke survivors. The findings of this systematic review will be disseminated publicly and in peer-reviewed journals and may be the topic of research presentations.

TRIAL REGISTRATION NUMBER

CRD42017067391.

Free smoking cessation mobile apps available in Australia: a quality review and content analysis

OBJECTIVES

This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines.

METHODS

A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines.

RESULTS

112 relevant apps were identified. The majority were of poor technical quality and only six 'high-quality' apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated.

CONCLUSIONS

In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

A systematic narrative review of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups (2010-2017)

INTRODUCTION

Tobacco remains the key modifiable risk factor for the development of a number of diseases, including cardiovascular disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis and cancer. Among priority populations, smoking prevalence remains high, smokers tend to relapse more often and earlier and fewer are able to sustain quit attempts. This systematic review provides an update on the literature. Areas covered: Twenty-four randomized controlled trials published from 2010-2017, in English language, were identified after searching on Medline, Ovid, Embase and PsycINFO databases. Studies reported on the effectiveness of smoking cessation interventions among six disadvantaged groups known to have high smoking rates: (i) homeless, (ii) prisoners, (iii) indigenous populations, (iv) at-risk youth, (v) people with low income, and (vi) those with a mental illness. Narrative review and assessment of methodological quality of included papers was undertaken. Expert commentary: There is a growing evidence base of methodologically robust studies evaluating a variety of behavioural smoking cessation interventions for priority populations. Multi-component interventions and those examining behavioural interventions incorporating mindfulness training, financial incentives, motivational interviewing and extended telephone-delivered counseling may be effective in the short-term, particularly for smokers on low incomes and people with a mental illness.

Addressing tobacco in Australian alcohol and other drug treatment settings: a cross-sectional survey of staff attitudes and perceived barriers

BACKGROUND

Within alcohol and other drug (AOD) services, staff attitudes and beliefs are important influences determining provision of smoking cessation care. This study of AOD staff aimed to examine: a) current attitudes toward smoking cessation care; b) service and staff characteristics associated with unsupportive smoking cessation care attitudes, and c) perceived barriers to providing smoking cessation care.

METHODS

Between July-October 2014, 506 staff from 31 Australian AOD services completed an online cross-sectional survey which assessed agreement with 6 attitudinal statements (supportive and unsupportive) and 10 perceived barriers to smoking cessation care in the AOD setting. Logistic regressions examined service (sector) and staff (age, gender, smoking status and number of years in AOD field) characteristics associated with unsupportive smoking cessation care attitudes.

RESULTS

A large proportion agreed with supportive statements: Smoking cessation care should be part of usual care (87%), smoking cessation care is as important as counselling about other drugs (72%) and staff have the organisational support to provide smoking cessation care (58%). Some respondents agreed with unsupportive statements: AOD clients are not interested in addressing their smoking (40%), increasing smoking restrictions would lead to client aggression (23%), smoking is a personal choice and it is not the service's role to interfere (16%). Respondents from non-government managed services, current tobacco smokers (compared to ex-smokers) and those with less AOD experience had higher odds of agreeing with unsupportive smoking cessation care statements. The most frequently identified barriers to providing smoking cessation care were: client inability to afford cessation medicines, insufficient funding and lack of a coordinated treatment approach (all 61%).

CONCLUSIONS

Overall, staff hold largely supportive smoking cessation care attitudes but perceive a large number of barriers to providing smoking cessation care.

Tobacco smoking policies in Australian alcohol and other drug treatment services, agreement between staff awareness and the written policy document

Background

Comprehensive smoke-free policy in the alcohol and other drug (AOD) setting provides an opportunity to reduce tobacco related harms among clients and staff. This study aimed to examine within AOD services: staff awareness of their service’s smoking policy compared to the written policy document and staff and service factors associated with accurate awareness of a total ban and perceived enforcement of a total ban.

Methods

An audit of written tobacco smoking policy documents and an online cross-sectional survey of staff from 31 Australian AOD services. In addition, a contact at each service was interviewed to gather service-related data.

Results

Overall, 506 staff participated in the survey (response rate: 57%). Nearly half (46%) perceived their service had a total ban with 54% indicating that this policy was always enforced. Over one-third (37%) reported a partial ban with 48% indicating that this policy was always enforced. The audit of written policies revealed that 19 (61%) services had total bans, 11 (36%) had partial bans and 1 (3%) did not have a written smoking policy. Agreement between staff policy awareness and their service’s written policy was moderate (Kappa 0.48) for a total ban and fair (Kappa 0.38) for a partial ban. Age (1 year increase) of staff was associated with higher odds of correctly identifying a total ban at their service.

Conclusions

Tobacco smoking within Australian AOD services is mostly regulated by a written policy document. Staff policy awareness was modest and perceived policy enforcement was poor.

The association between cannabis use and motivation and intentions to quit tobacco within a sample of Australian socioeconomically disadvantaged smokers

This study aimed to (i) describe concurrent and simultaneous tobacco and cannabis use and (ii) investigate the association between cannabis use and motivation and intentions to quit tobacco in a sample of socioeconomically disadvantaged smokers. A cross-sectional survey was conducted in 2013 and 2014 with current tobacco smokers receiving aid from two community service organizations in New South Wales, Australia. At least weekly cannabis use for the month prior to survey, motivation to quit tobacco and intentions to quit tobacco were measured in 369 participants (77% consent rate). Regressions were carried out to investigate associations between weekly cannabis use and motivation and intentions to quit tobacco.Concurrent tobacco and cannabis use was reported by 19% (n = 71) of the sample and of these users, 100% reported simultaneous use. Although regular cannabis use was significantly associated with lower motivation to quit tobacco, it was not significantly associated with intentions to quit tobacco in the next 30 days. Concurrent cannabis use is common in disadvantaged smokers and may play a role in decreased motivation to quit tobacco; however, it does not appear to be associated with intentions to quit in a sample of disadvantaged smokers.

Smoking cessation care among patients with head and neck cancer: a systematic review

OBJECTIVE

To examine the effectiveness of smoking cessation interventions in improving cessation rates and smoking related behaviour in patients with head and neck cancer (HNC).

DESIGN

A systematic review of randomised and non-randomised controlled trials.

METHODS

We searched the following data sources: CENTRAL in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL up to February 2016. A search of reference lists of included studies and Google Scholar (first 200 citations published online between 2000 and February 2016) was also undertaken. The methodological quality of included studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). 2 study authors independently screened and extracted data with disagreements resolved via consensus.

RESULTS

Of the 5167 studies identified, 3 were eligible and included in the review. Trial designs of included studies were 2 randomised controlled trials and 1 non-randomised controlled trial. 2 studies received a weak methodological rating and 1 received a moderate methodological rating. The trials examine the impact of the following interventions: (1) nurse delivered cognitive-behaviour therapy (CBT) via telephone and accompanied by a workbook, combined with pharmacotherapy; (2) nurse and physician brief advice to quit and information booklets combined with pharmacotherapy; and (3) surgeon delivered enhanced advice to quit smoking augmented by booster sessions. Only the trial of the nurse delivered CBT and pharmacotherapy reported significant increases in smoking cessation rates. 1 study measured quit attempts and the other assessed consumption of cigarettes per day and readiness to change. There was no significant improvement in quit attempts or cigarettes smoked per day among patients in the intervention groups, relative to control.

CONCLUSIONS

There are very few studies evaluating the effectiveness of smoking cessation interventions that report results specific to the HNC population. The 3 trials identified reported equivocal findings. Extended CBT counselling coupled with pharmacotherapy may be effective.

TRIAL REGISTRATION NUMBER

CRD42016016421.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial

Background

The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services.

Methods/design

A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care.

Discussion

If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549. Registered on 3 March 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1401-6) contains supplementary material, which is available to authorized users.

Self-Exempting Beliefs and Intention to Quit Smoking within a Socially Disadvantaged Australian Sample of Smokers

An investigation of beliefs used to rationalise smoking will have important implications for the content of anti-smoking programs targeted at socioeconomically disadvantaged groups, who show the lowest rates of cessation in the population. This study aimed to assess the types of self-exempting beliefs reported by a sample of socioeconomically disadvantaged smokers, and identify associations between these beliefs and other smoking-related factors with quit intentions. A cross-sectional survey was conducted from March-December 2012 with smokers seeking welfare assistance in New South Wales (NSW), Australia (n = 354; response rate 79%). Responses to a 16-item self-exempting beliefs scale and intention to quit, smoker identity, and enjoyment of smoking were assessed. Most participants earned <AUD$400/week (70%), and had not completed secondary schooling (64%). All "jungle" beliefs (normalising the dangers of smoking due to ubiquity of risk) and selected "skeptic" beliefs were endorsed by 25%-47% of the sample, indicating these smokers may not fully understand the extensive risks associated with smoking. Smokers with limited quit intentions held significantly stronger self-exempting beliefs than those contemplating or preparing to quit (all p < 0.01). After adjusting for smoking-related variables only "skeptic" beliefs were significantly associated with intention to quit (p = 0.02). Some of these beliefs are incorrect and could be addressed in anti-smoking campaigns.

Which Type of Antismoking Advertisement Is Perceived as More Effective? An Experimental Study With a Sample of Australian Socially Disadvantaged Welfare Recipients

PURPOSE

Evaluate the perceived effectiveness of key antismoking messages among highly disadvantaged smokers and assess the impact of nicotine dependence and cessation cognitions on message processing.

DESIGN

The experimental crossover trial, undertaken between March and December 2012, randomly exposed participants to two of three antismoking advertisements delivered via touchscreen computer.

SETTING

Welfare recipients were recruited from a community service organization in New South Wales, Australia.

SUBJECTS

Subjects were 354 smokers (79% response rate). Participants resided in government rental housing (52%), earned less than AUD$400/wk (72%), and received their primary income from government welfare (95%).

INTERVENTION

Three 30-second antismoking television advertisements representing common campaign themes: why to quit (graphic imagery), why to quit (personal testimonial), or how to quit.

MEASURES

An 11-item scale assessed perceived effectiveness and message acceptance. An eight-item cessation cognitions index assessed motivations and readiness to quit, and the heaviness of smoking index was used to classify nicotine dependence.

ANALYSIS

Descriptive statistics, generalized linear mixed models, and multiple linear regression analyses are reported.

RESULTS

Why-to-quit advertisements were perceived as significantly more effective than the how-to-quit advertisement (all p < .0001). Smokers with positive cessation cognitions were more likely to accept antismoking messages (p = .0003) and perceive them as effective (p < .0001). Nicotine dependence level did not influence message acceptance (p = .7322) or effectiveness (p = .8872).

CONCLUSION

Highly emotive advertisements providing good reasons to quit may be the most effective in promoting the antismoking message among groups with high smoking rates.

Electronic Cigarettes: Awareness, Recent Use, and Attitudes Within a Sample of Socioeconomically Disadvantaged Australian Smokers

INTRODUCTION

Electronic cigarette (e-cigarette) awareness, trial of e-cigarettes in the past 12 months, source and perceptions of safety and effectiveness was assessed within a disadvantaged sample of adult Australian smokers receiving welfare aid.

METHODS

A cross-sectional survey was administered to clients who smoke at two community service organizations in New South Wales, Australia from October 2013 to July 2014. E-cigarette awareness, trial in past 12 months, sources of e-cigarettes and perceptions of the safety and effectiveness of e-cigarettes to help people quit were assessed along with sociodemographic and smoking-related variables.

RESULTS

In total, 369 participants completed the survey (77% response rate). Awareness and trial of e-cigarettes were reported by 77% (n = 283) and 35% (n = 103) of the sample, respectively. E-cigarettes were most commonly obtained from friends/strangers followed by tobacco shops (tobacconists). Trying e-cigarettes in the past 12 months was significantly associated with positive perceptions of their safety (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1, 3.1) and effectiveness (OR = 1.9, 95% CI = 1.1, 3.2). Motivation to quit tobacco smoking was also significantly positively associated with positive perceptions of e-cigarette safety (OR = 1.2, 95% CI = 1.1, 1.4) and effectiveness (OR = 1.2, 95% CI = 1.0, 1.3).

CONCLUSIONS

Rates of awareness and trial of e-cigarettes within a disadvantaged sample of Australian smokers are comparable to rates found within representative samples of the general Australian population. Previously trying e-cigarettes and higher levels of motivation to quit were associated with more positive perceptions of e-cigarette safety and effectiveness.

IMPLICATIONS

This study demonstrates that socioeconomically disadvantaged smokers are aware of and accessing e-cigarettes in a country with relatively high restrictions covering e-cigarette sale and use.

Comparing socially disadvantaged smokers who agree and decline to participate in a randomised smoking cessation trial

OBJECTIVES

This study examined sociodemographic, smoking and psychosocial characteristics associated with consent to participate in a smoking cessation trial for socially disadvantaged smokers.

DESIGN

Baseline data were collected prior to seeking consent for the Call it Quits, a randomised controlled trial.

SETTING

An Australian social and community service organisation. Sociodemographic, smoking and psychosocial characteristics were compared between smokers who agreed or declined to participate.

PARTICIPANTS

Of the 584 smokers invited to participate, 431 (74%) consented and 153 (26%) declined.

RESULTS

Logistic regression modelling indicates the ORs of participation were twice as high for those reporting 'high' motivation to quit compared to the 'moderate' motivation group, and five times higher than the 'low' motivation group (p=0.007). The ORs of consenting were higher for those with a preference for gradual reduction in cigarettes in quit attempts compared with 'no preference'. The ORs were lower for those reporting 'don't know' regarding their enjoyment of smoking compared to 'not at all' enjoying smoking, and reporting that fewer of their family or friends smoked compared to 'most or all'.

CONCLUSIONS

This study is the first to examine the characteristics of socially disadvantaged smokers who consent or decline to participate in a smoking cessation trial. Low-income smokers who are motivated to quit, are not enjoying smoking, had family or friends who smoked, and who are interested in gradual cessation approaches may be more likely to participate in a smoking cessation trial.

TRIAL REGISTRATION NUMBER

ISRCTN85202510.

'The lesser of two evils': A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings

INTRODUCTION AND AIMS

The aim of this study was to explore beliefs about tobacco dependence treatment from the perspective of staff and clients in addiction treatment settings.

DESIGN AND METHODS

A qualitative study was conducted between August and November 2013 using grounded theory methodology. Participants were recruited from four government-funded drug and alcohol services in a regional centre of New South Wales, Australia. Treatment centre staff (n = 10) were interviewed using a semistructured interview guide and two focus groups (n = 5 and n = 6) were held with clients of the same treatment centres.

RESULTS

Both clients and staff wish to do more about tobacco use in addiction treatment services, but a number of barriers were identified. Staff barriers included lack of time, tobacco-permissive organisational culture, lack of enforcement of smoke-free policies, beliefs that tobacco is not a treatment priority for clients and that clients need to smoke as a coping strategy, and perceptions that treatment was either ineffective or not used by clients. Clients reported smoking as a habit and for enjoyment or stress relief, seeing staff smoking, nicotine replacement therapy unaffordability and perceptions that nicotine replacement therapy may be addictive, and inability to relate to telephone cessation counselling as barriers to quitting smoking.

DISCUSSION AND CONCLUSIONS

Client and staff perceptions and attitudes about the treatment of tobacco, particularly those relating telephone support and nicotine replacement therapy, provided information, which will inform the design of smoking cessation programs for addiction treatment populations. [Wilson AJ, Bonevski B., Dunlop A., Shakeshaft A, Tzelepis F., Walsberger S., Farrell M., Kelly PJ, Guillaumier A. 'The lesser of two evils': A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings. Drug Alcohol Rev 2015].

'Cigarettes are priority': a qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices

Despite substantial modelling research assessing the impact of cigarette taxes on smoking rates across income groups, few studies have examined the broader financial effects and unintended consequences on very low-income smokers. This study explored how socioeconomically disadvantaged smokers in a high-income country manage smoking costs on limited budgets. Semi-structured face-to-face interviews were conducted with 20 smokers recruited from a welfare organization in NSW, Australia. Participants discussed perceived impact of tobacco costs on their essential household expenditure, smoking behaviour and quit cognitions. Interviews were audio-taped, transcribed verbatim and analysed using thematic framework analysis. Instances of smoking-induced deprivation and financial stress, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes were reported as routine experiences. Price-minimization strategies and sharing tobacco resources within social networks helped to maintain smoking. Participants reported tobacco price increases were good for preventing uptake, and that larger price rises and subsidized cessation aids were needed to help them quit. Socioeconomically disadvantaged smokers engage in behaviours that exacerbate deprivation to maintain smoking, despite the consequences. These data do not suggest a need to avoid tobacco taxation, rather a need to consider how better to assist socioeconomically disadvantaged smokers who struggle to quit.

Targeting multiple health risk behaviours among vocational education students using electronic feedback and online and telephone support: protocol for a cluster randomised trial

BACKGROUND

Technical and Further Education (TAFE) colleges are the primary provider of vocational education in Australia. Most TAFE students are young adults, a period when health risk behaviours become established. Furthermore, high rates of smoking, risky alcohol consumption, inadequate fruit and vegetable intake and insufficient physical activity have been reported in TAFE students. There have been no intervention studies targeting multiple health risk behaviours simultaneously in this population. The proposed trial will examine the effectiveness of providing TAFE students with electronic feedback regarding health risk behaviours and referral to a suite of existing online and telephone services addressing smoking, risky alcohol consumption, fruit and vegetable intake, and physical activity levels.

METHODS/DESIGN

A two arm, parallel, cluster randomised trial will be conducted within TAFE campuses in New South Wales (NSW), Australia. TAFE classes will be randomly allocated to an intervention or control condition (50 classes per condition). To be eligible, students must be: enrolled in a course that runs for more than 6 months; aged 16 years or older; and not meet Australian health guideline recommendations for at least one of the following: smoking, alcohol consumption, fruit and/or vegetable intake, or physical activity. Students attending intervention classes, will undertake via a computer tablet a risk assessment for health risk behaviours, and for behaviours not meeting Australian guidelines be provided with electronic feedback about these behaviours and referral to evidence-based online programs and telephone services. Students in control classes will not receive any intervention. Primary outcome measures that will be assessed via online surveys at baseline and 6 months post-recruitment are: 1) daily tobacco smoking; 2) standard drinks of alcohol consumed per week; 3) serves of fruit consumed daily; 4) serves of vegetables consumed daily; and 5) metabolic equivalent minutes of physical activity per week.

DISCUSSION

Proactive enrolment to existing online and telephone services has the potential to address modifiable determinants of disease. This trial will be the first to examine a potentially scalable intervention targeting multiple health risk behaviours among students in the vocational training setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000105549; Registered 5/2/15.

Tobacco health warning messages on plain cigarette packs and in television campaigns: a qualitative study with Australian socioeconomically disadvantaged smokers

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few studies have examined how high smoking prevalence groups respond to these warnings. This study explored how socioeconomically disadvantaged smokers engage with health risk and cessation benefit messages. Six focus groups were conducted over September 2012-April 2013 with adult clients of welfare organizations in regional New South Wales, Australia who were current smokers (n = 51). Participants discussed HWLs, plain packaging and anti-smoking television advertisements. Discussions were audio-taped, transcribed verbatim and analysed using thematic analysis. Highly emotive warnings delivering messages of negative health effects were most likely to capture the attention of the study participants; however, these warning messages did not prompt quit attempts and participants were sceptical about the effectiveness of cessation programmes such as telephone quitlines. Active avoidance of health warning messages was common, and many expressed false and self-exempting beliefs towards the harms of tobacco. Careful consideration of message content and medium is required to communicate the anti-smoking message to disadvantaged smokers who consider themselves desensitized to warnings. Health communication strategies should continue to address false beliefs about smoking and educate on cessation services that are currently underutilized.

The vocational education setting for health promotion: a survey of students' health risk behaviours and preferences for help

BACKGROUND

Adolescence and young adulthood is a time of risky health behaviour initiation and experimentation. Smoking, risky drinking, poor nutrition and physical activity, and a lack of sun protection behaviour, often become established in early adulthood. Levels of health risk behaviours occurring amongst tertiary education and training students and their preferences for types of on-campus health promotion programs were examined.

METHOD

A cross-sectional pen-and-paper classroom survey was conducted at one Sydney-based TAFE New South Wales Institute campus in May 2010. The survey assessed demographics, smoking, alcohol use, sun protection, nutrition, physical activity and health promotion program preferences.

RESULTS

Two hundred and twenty-four students participated (97% consent); the majority were aged 16-24 years (59%) and female (51%). Current smoking (35%), risky drinking (49%) and inadequate physical activity (88%) rates were high. Adequate vegetable intake (3.6%) and sun protection behaviours (5.4%) were low and 33% of students were overweight or obese. Popular health promotion programs included food and activity subsidies, practical skills classes and social outings.

CONCLUSION

Participation in health risk behaviours among this sample was high. The setting of tertiary education and workplace training represents an opportunity for early intervention into risky health behaviours among young people. SO WHAT?: This study is the first to provide information on the prevalence of health risk behaviours and preferences for types of health promoting programs among students of an Australian community college. The results show that young adults regularly participate in multiple health risk behaviours, such as smoking, drinking, poor nutrition, physical activity and lack of sun protection.

Socioeconomically disadvantaged smokers' ratings of plain and branded cigarette packaging: an experimental study

OBJECTIVES

This study aimed to test the potential impact of plain packaging for cigarettes on brand appeal among highly socioeconomically disadvantaged smokers using the new design for cigarettes implemented in Australia, which combines plain packaging with larger health warning labels.

DESIGN

A 2×2 factorial design trial embedded within a cross-sectional computer touchscreen survey. Data were collected between March and December 2012.

SETTING

Socially disadvantaged welfare aid recipients were recruited through a large Social and Community Service Organisation in New South Wales, Australia.

PARTICIPANTS

N=354 smokers. The majority of the sample had not completed high school (64%), earned less than $A300/week (55%) and received their income from Government payments (95%).

INTERVENTIONS

Participants were randomised to one of the four different pack conditions determined by brand name: Winfield versus Benson & Hedges, and packaging type: branded versus plain. Participants were required to rate their assigned pack on measures of brand appeal and purchase intentions.

RESULTS

Plain packaging was associated with significantly reduced smoker ratings of 'positive pack characteristics' (p<0.001), 'positive smoker characteristics' (p=0.003) and 'positive taste characteristics' (p=0.033) in the Winfield brand name condition only. Across the four pack conditions, no main differences were found for 'negative smoker characteristics' (p=0.427) or 'negative harm characteristics' (p=0.411). In comparison to plain packaging, the presentation of branded packaging was associated with higher odds of smokers' purchase intentions (OR=2.18, 95% CI 1.34 to 3.54; p=0.002).

CONCLUSIONS

Plain packs stripped of branding elements, featuring larger health warning labels, were associated with reduced positive cigarette brand image and purchase intentions among highly socioeconomically disadvantaged smokers.

Paying the price: a cross-sectional survey of Australian socioeconomically disadvantaged smokers' responses to hypothetical cigarette price rises

INTRODUCTION AND AIMS

Increases in tobacco taxation can lead to reductions in tobacco consumption and prevalence of use across social groups. However, use of price-minimisation strategies to manage current and future tobacco use and the role of financial stress is less understood. This study aimed to measure the effect of cigarette price increases on price-minimisation strategy endorsement and financial stress among socioeconomically disadvantaged smokers.

DESIGN AND METHODS

Community service organisation welfare recipients in NSW, Australia completed a touchscreen survey. Smoking history, financial stress, highest price to quit and responses to hypothetical cigarette price increases were assessed.

RESULTS

Participants were 354 smokers (response rate = 79%). Most participants received income from a government pension (95%), earned <A$300/week (55%), had not completed secondary schooling (64%), were moderately or heavily nicotine-dependent (60%), reported high financial stress (66%) and spent A$56/week on tobacco. In response to 10% and 20% hypothetical price rises, significantly more participants endorsed trying to quit in response to the larger increase scenario (P < 0.001), and fewer selected no change to their smoking (P < 0.001). Numerous price-minimisation strategies (e.g. switching to cheaper brands/products) were endorsed, but remained constant across hypothetical scenarios; level of financial stress appeared to have little influence. Smokers indicating they would not change their smoking in response to price rises had higher levels of nicotine dependence.

DISCUSSION AND CONCLUSIONS

Socially disadvantaged smokers endorsed numerous price-minimising strategies to maintain smoking at hypothetically increased costs. Larger cigarette price rises motivated more smokers to consider quitting, while price-resistant smokers appeared to have a more entrenched smoker status.

Anti-tobacco mass media and socially disadvantaged groups: a systematic and methodological review

ISSUES

Only a limited amount of research has been conducted to explore whether there are socioeconomic status differences in responses to mass media. However, the methodological quality of this evidence has not been assessed, limiting confidence in conclusions that can be drawn regarding study outcomes. A systematic review of the effectiveness of anti-tobacco mass media campaigns with socially disadvantaged groups was conducted, and the methodological quality of included studies was assessed.

APPROACH

Medline, The Cochrane Library, PsycInfo, Embase and Web of Science were searched using MeSH and keywords for quantitative studies conducted in Western countries prior to March 2012. A methodological quality assessment and narrative analysis of included studies was undertaken.

KEY FINDINGS

Seventeen relevant studies (reported in 18 papers) were identified; however, weak study designs and selection bias were common characteristics, limiting strong conclusions about effectiveness. Using predominantly non-cessation related outcome measures reviewed papers indicated mixed results for mass media tobacco control campaign effectiveness among various social groups. Most studies assessed mass media impact on low socioeconomic status groups rather than highly socially disadvantaged groups.

IMPLICATIONS

Methodological rigour of evaluations in this field must be improved to aid understanding regarding the effectiveness of mass media campaigns in driving cessation among disadvantaged groups.

CONCLUSION

The results of this review indicate a gap in methodologically rigorous research into the effectiveness of mass media campaigns among socially disadvantaged groups, particularly the highly disadvantaged.