Jan Robertson

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

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

The gap in tobacco use between remote Indigenous Australian communities and the Australian population can be closed

The Australian Prime Minister’s historic apology to the “stolen generations” in February 2008 included commitments to close the life expectancy gap between Indigenous and non-Indigenous Australians “within a generation”. In a subsequent speech, the Health Minister reasoned: “Indigenous Australians need to play their part too” and “it is ultimately up to individuals to modify their behaviour to reduce their exposure to illness”.1 Preliminary results of a survey of tobacco use in remote communities indicate that the majority of Indigenous smokers want to quit but adequate support has not been available.

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

Objective: To review available literature addressing the issue of whether smoking status of Indigenous Health Workers (IHWs) impedes provision of health information about smoking tobacco to their communities.

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

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

Tackling Tobacco: A Call to Arms for Remote Area Nurses

Abstract Tobacco-related conditions contribute significantly to the health gap between Indigenous and non-Indigenous Australians. Smoking rates in Australia’s Indigenous population has failed to decline even though smoking rates in Australia have declined in general. In some Indigenous communities, smoking rates remain very high. This paper outlines a project to investigate appropriate strategies to assist Indigenous smokers to quit and the important role nurses can play.

We Made the Rule, We Have to Stick to It: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities

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

Establishing smoke-free homes in the Indigenous populations of Australia, New Zealand, Canada and the United States: a systematic literature review

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

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

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

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

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

HIGH PREVALENCE OF CANNABIS USE, MENTAL HEALTH IMPACTS, AND POTENTIAL INTERVENTION STRATEGIES: DATA FROM THE CAPE YORK CANNABIS PROJECT

Introduction and Aims: High rates of cannabis use and dependence are significant issues in remote Indigenous communities. We have previously shown extremely high rates of cannabis use, dependence and adverse mental health impacts in Arnhem Land. This study reports the first data on cannabis use and its mental health impacts in Cape York. Design and Methods: We interviewed over 300 Aboriginal people aged 16–40 years in three remote Cape York communities. Data was gathered on rates of cannabis use, mental health impacts including dependence and withdrawal, and reasons for quitting. Results: One in two individuals interviewed was using cannabis, with most using cannabis daily or weekly. Approximately 70% reported cannabis dependence. Encouragingly, more than 70% of current users were considering quitting/cutting down or had made previous attempts. In current users, seeking or starting employment was the most common motivation for wanting to quit, whilst former users quit primarily for family reasons. Users reported negative mental health impacts of cannabis. One in four reported ‘stressing out’ when cannabis was unavailable, suggesting withdrawal. Anger/ irritability, paranoia, auditory hallucinations, thoughts of suicide/ self-harm and memory impairment were reported in up to 10% of users. Discussion and Conclusions: Rates of use and dependence are much higher than national rates (4.9% of males and 2.2% of females nationally used cannabis in the past week, 21% exhibiting dependence), and are similar to Northern Territory rates. One in four Aboriginal users in remote communities may be suffering mental ill health. Interventions should enhance quit support and employment opportunities and strengthen families.Introduction and Aims: Wastewater analysis has become a useful technique for monitoring illicit drug use in communities. Findings have been reported from different countries in Europe and North America. We applied this technique to gauge the illicit drug consumption in an urban catchment from South East Queensland, Australia. Design and Methods: The sampling campaigns were conducted in 2009 (21st November – 2nd December) and 2010 (19th – 25th November). We collected daily composite wastewater samples from the inlet of the sewage treatment plant using continuous flow-proportional sampling. Ten illicit drug residues (parent compounds and key metabolites) in the samples were measured using liquid chromatography coupled to tandem mass spectrometer. Results: Seven compounds were quantified in all the samples. Our data indicated higher drug consumption on weekends. Cannabis was the highest used drug in both sampling periods. Compared to the first sampling campaign which indicated that cocaine and methamphetamine use exceeded ecstasy usage, the second sampling campaign suggested the use of methamphetamine exceeded that of ecstasy which in turn exceeded cocaine use. Discussion and Conclusions: The observed weekly trend of drug use in our study is in agreement with findings in other studies. The variation between two sampling periods in the prevalence of drug use may relate to the availability and prices of the drugs on markets. The cocaine use we estimated in 2009 was much greater than estimations obtained through the national household survey [1], implying under- reporting of cocaine use in surveys. Future work is underway to tackle methodological challenges for more accurate estimation.