Literature Review: Evaluation Studies on Tobacco Smoking Health Promotion Programs for the Indigenous Australian Population Introduction Tobacco smoking is one of the main causes of major diseases in Australia and is still the largest single preventable cause of death (AIHW, 2008). Smoking counts for 15,500 deaths annually and higher mortality and morbidity are found among Indigenous populations (AIHW, 2008). In Australia, the smoking prevalence is higher among the Aboriginal People and Torres Strait Islanders. Approximately 34. % of Indigenous Australians are smoking, compared to only 19% in the general populations (ABS, 2006). The high smoking prevalence is highly correlated with the premature deaths and morbidity among Indigenous people, which mainly caused by cardiovascular disease, respiratory disease and other diseases related to tobacco use, resulting in 18 years of life expectancy gap between Indigenous people and the general populations (AIHW, 2008). Australia is one of the most successful countries in implementing smoking cessation programs, but unfortunately Indigenous population’s smoking rates remain high (AIHW, 2008).
This disparity between the Indigenous and Australian general population is highly correlated with the differences in health determinants (Lindorff, 2002), such as the lower socioeconomic status and cultural differences. Therefore, in order to address smoking problems in this particular community, there is a need to also address these determinants, such as culturally-appropriate approaches and economically feasible smoking cessation programs. The current smoking cessation programs are well documented and evaluated for the Australian general populations, but unfortunately not for Indigenous people.
There have been few discussions regarding which smoking interventions are effective for Indigenous population (Boffa et al. 2009) and about the potential of existing programs for this particular population. This review analyzes several evaluation studies on smoking cessation programs and their limitations. In the conclusion, this paper gives several recommendations on how to improve the evaluations and suggestions on programs that have potential benefit if applied in the Indigenous populations. Health Promotion Interventions
This review analyzes the evaluations of two types of smoking cessation programs; quit smoking programs in individual or group basis, and health promotion program which uses social marketing approach such as quit smoking advertisements which cover larger communities. Quit smoking programs There are strong evidences supporting the use of pharmacotherapy and counseling in helping smokers to quit their smoking behavior (Raw et al. 1999; Ivers, 2004). In Aboriginal population, there have been numerous projects in smoking cessation, but there are only limited evaluation studies on current programs.
The following review discussed two evaluation studies on smoking cessation programs with several differences and findings. There are a number of studies evaluating smoking cessation programs which use the combination of counseling and nicotine replacement therapy (Ivers et al. 2003; Mark et al. 2004). The evaluation study by Mark et al (2004) took place in an Aboriginal community in New South Wales, using qualitative and quantitative methods to assess the smoking cessation program with three months follow up. The program used the combination between support groups and nicotine replacement therapy (NRT).
In this evaluation study, selected participants were assessed using pre and post-course surveys with a three months follow up. In the end of the program, only 6. 1% of the participants remain tobacco-free. When asked the reason or difficulties in quitting smoking, respondents complained the side effects of NRT, including skin irritation, nightmares and tiredness. There was also no supportive environments which keep the smokers motivated to quit smoking, for example their families are permissive for them to smoke and do not really support them to quit. These reasons are similar with the findings in an evaluation study by Ivers et al (2003).
However, Ivers et al (2003) found that the success rate among the Indigenous people participating in the program was similar with general population (15% vs 17%). This difference may occurred because in Ivers et al’s study, the program provided free nicotine patches throughout the entire length of the program. But, even though the outcome in smoking cessation rate was low in Mark et al’s study (2004), the evaluation managed to assess the participants’ willingness and confidence that they may try to quit smoking again in the future and the number of times they have tried to quit.
This information may be beneficial, since research suggests that in general population, smokers on average tried to quit five to seven times before they succeed (Duncan et al. 2002). In the study by Mark et al (2004), the program itself was not very successful in reducing smoking rates, but the evaluation study also had some methodological limitations. There was a lack of control group to objectively compare the efficacy of the program, and the respondents were self-selected without randomization, which further limiting the validity of the study. There was also poor follow up where only 31. % and 13% of the participants completed the post-course and three-months follow up survey, respectively. On the other hand, study by Ivers et al (2003) managed to follow up 84% of the participants and used carbon monoxide validation to confirm the self-reported smoking abstinence, which was not done in Mark et al (2004). The failure to use a biomarker, such as carbon monoxide validation, may imply that the quit rates might be even lower than what the study recorded. The main difference in the programs which Ivers et al (2003) and Mark et al (2004) evaluated was in the provision of free nicotine replacement therapy.
In Ivers et al (2003), the nicotine patch was provided free of charge throughout the entire program, but only for three weeks in the program evaluated by Mark et al (2004). There are still very limited programs which address the barrier of the nicotine replacement therapy price for the Indigenous communities (Boffa et al, 2009). It is important to address this issue, since socioeconomic status is an important determinant of tobacco smoking among Indigenous people (Baker et al, 2006; Miller & Hickling, 2004; Thomas et al. 2008).
The evaluation study by Ivers et al (2003), if compared to Mark et al (2004), was more rigorous in terms of follow up rates and the use of biomarker validation, but both studies did not use randomized controlled trial, which compromised the validity of the evaluation and could not be generalized in larger population. As was suggested by Baker et al (2006), larger randomized controlled trial in several community settings and more tailored approach could benefit in examining proper strategies in promoting smoking cessation.
But even with the limitation of the studies, both studies showed that addressing the economic limitation might be beneficial in the success of smoking cessation programs. Social Marketing Activities Social marketing campaigns aim to raise awareness of smoking behavior, altering the attitudes and advocating cultural change for actions affecting health. This approach utilizes a combination of promotional strategies and media campaign aimed at the target populations. Culturally appropriate quit smoking promotion programs could benefit the social marketing approach for Indigenous people.
Several studies (Ivers, 2003; Hassard, 1999) have shown that the Indigenous people are actually quite aware about the anti-smoking media campaigns, but their smoking rates remain high because the quit message was not well-memorized or taken seriously. One explanation was given by O’Connor et al (1999) who found that the Indigenous people prefer materials which used visual media or easy to read with colorful pictures that are more cultural-friendly. To address this cultural issue, program such as Talkin’ Up Good Air (2008) has adopted well-designed social marketing campaign which use Aboriginal artworks.
Davis et al (2004) has conducted a well-controlled evaluation study that showed that the culturally appropriate health education resources were well accepted and the use of the traditional artworks provides a viable method for Aboriginal health promotion. In their evaluation study, Davis et al (2004) provided a solid suggestion because it was well conducted with high follow-up rates and included active role from the community elders, which gave better understanding from the local perspectives. Other intervention for social marketing involves messages that will strongly affect the Indigenous community.
For example, Boffa et al (2009) evaluated a campaign which focused on the harmful effects of tobacco on the children and family, not just the individual smoker. The program gave stronger impact in the respondents’ perception and understanding, but unfortunately the study did not assess the long term effectiveness of this program and the actual effect on smoking rates. Media campaigns are cost effective and could reach a wide range of communities. In one study, Dale (1999) identified there are several available interventions that specifically target the Indigenous people.
One study that was evaluated is the development of radio advertisement in the Western Australian Quit Campaign and the Jabby Don’t Smoke Project. The evaluation study was done qualitatively in three Aboriginal communities, involving the role of the Elders and selected participants. The quit campaign advertisements were well recalled by the Indigenous people and resulted in initial attempts to quit smoking. The respondents’ perception and acceptability on the content of the campaign were also assessed, which gave a better understanding on how to improve the culturally appropriate campaign programs.
However, this evaluation did not assess the actual smoking cessation rates of the communities and lack of long term evaluation. An evaluation study on mass campaign was conducted by Ivers et al (2006) in six Aboriginal communities. This study used three matched control communities to measure changes in knowledge and attitudes of smoking behavior among the Aboriginal people. The program itself includes health promotion campaigns, school education on tobacco smoking, sports sponsorship, and the policy on smoke-free public area. The study used pre and post study to assess the program’s impacts, and a one year follow up.
The study was able to assess the decline in tobacco consumption by measuring the tobacco turnover rates from the tobacco vendors in the communities. This measurement is objective and was also used in other successful studies (COMMIT Research Group, 1995; Goto, 1998). The evaluation found that there were knowledge improvement in the health effects of tobacco and also increased willingness to quit. However, the program itself did not reduce the prevalence of tobacco consumption and it was difficult for the study to determine if the decline in tobacco turnover was really due to the program, despite the control groups used.
Generic media campaigns may also still quite effective for Indigenous people. As shown by a New Zealand evaluation study which interestingly found that the Maori-specific television campaigns actually have less impact in the call rates to the Quitline compared to the general ‘Every cigarette is doing you damage’ television advertisements (Wilson et al. 2005). This finding implies that the mainstream campaigns are still quite effective, but warrant the assessment of other mitigating factors such as access to resources. Conclusion
Smoking is causing a large health gap between the Indigenous and non-Indigenous population of Australia. This mainly caused by the differences in socioeconomic status and the cultural distinction. Current existing programs for smoking cessation in Australia have been very successful for the general population. However, to achieve the same effectiveness for Indigenous population there should be specific and well-directed attention for this particular population. This review only addresses two types of smoking cessation health promotion programs; the quit smoking program and the social marketing campaign.
From these two categories, there are some promising programs that need long term evaluation with better methodology such as the free nicotine replacement therapy provision. There are also some potential programs that can be further developed by using culturally appropriate approaches, for example the quit smoking advertisement. Therefore, in order to assess and design programs which address the underlying health determinants in the Indigenous population, more rigorous evaluation studies are warranted. References Australian Bureau of Statistics, 2006.
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