Kerrin Palazzi

Opportunities missed: a cross-sectional survey of the provision of smoking cessation care to pregnant women by Australian general practitioners and obstetricians

IntroductionnSimilar to other high-income countries, smoking rates in pregnancy can be high in specific vulnerable groups in Australia. Several clinical guidelines exist, including the 5As (Ask, Advice, Assess, Assist, and Arrange), ABCD (Ask, Brief advice, Cessation, and Discuss), and AAR (Ask, Advice, and Refer). There is lack of data on provision of smoking cessation care (SCC) of Australian General Practitioners (GPs) and Obstetricians.nnnMethodsnA cross-sectional survey explored the provision of SCC, barriers and enablers using the Theoretical Domains Framework, and the associations between them. Two samples were invited: (1) GPs and Obstetricians from a college database (n = 5571); (2) GPs from a special interest group for Indigenous health (n = 500). Dimension reduction for the Theoretical Domains Framework was achieved with factor analysis. Logistic regression was carried out for performing all the 5As and the AAR.nnnResultsnPerforming all of the 5As, ABCD, and AAR often and always was reported by 19.9%, 15.6%, and 49.2% respectively. Internal influences (such as confidence in counselling) were associated with higher performance of the 5As (Adjusted OR 2.69 (95% CI 1.5, 4.8), p < .001), whereas External influences (such as workplace routine) were associated with higher performance of AAR (Adjusted OR 1.7 (95% CI 1, 2.8), p = .035).nnnConclusionsnPerformance in providing SCC to pregnant women is low among Australian GPs and Obstetricians. Training clinicians should focus on improving internal influences such as confidence and optimism. The AAR may be easier to implement, and interventions at the service level should focus on ensuring easy, effective, and acceptable referral mechanisms are in place.nnnImplicationsnImproving provision of the 5As approach should focus on the individual level, including better training for GPs and Obstetricians, designed to improve specific internal barriers such as confidence in counselling and optimism. The AAR may be easier to implement in view of the higher overall performance of this approach. Interventions on a more systemic level need to ensure easy, effective, and acceptable referral mechanisms are in place. More research is needed specifically on the acceptability of the Quitline for pregnant women, both Indigenous and non-Indigenous.

Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting

OBJECTIVEnTo examine the effect of universal, school-based, resilience-focused interventions on mental health problems in children and adolescents.nnnMETHODnEligible studies were randomized controlled trials (RCTs) of universal, school-based interventions that included strategies to strengthen a minimum of 3 internal resilience protective factors, and included an outcome measure of mental health problems in children and adolescents aged 5 to 18 years. Six databases were searched from 1995 to 2015. Results were pooled in meta-analyses by mental health outcome (anxiety symptoms, depressive symptoms, hyperactivity, conduct problems, internalizing problems, externalizing problems, and general psychological distress), for all trials (5-18 years). Subgroup analyses were conducted by age (child: 5-10 years; adolescent: 11-18 years), length of follow-up (short: post-≤12 months; long: >12 months), and gender (narrative).nnnRESULTSnA total of 57 included trials were identified from 5,984 records, with 49 contributing to meta-analyses. For all trials, resilience-focused interventions were effective relative to a control in reducing 4 of 7 outcomes: depressive symptoms, internalizing problems, externalizing problems, and general psychological distress. For child trials (meta-analyses for 6 outcomes), interventions were effective for anxiety symptoms and general psychological distress. For adolescent trials (meta-analyses for 5 outcomes), interventions were effective for internalizing problems. For short-term follow-up, interventions were effective for 2 of 7 outcomes: depressive symptoms and anxiety symptoms. For long-term follow-up (meta-analyses for 5 outcomes), interventions were effective for internalizing problems.nnnCONCLUSIONnThe findings may suggest most promise for using universal resilience-focused interventions at least for short-term reductions in depressive and anxiety symptoms for children and adolescents, particularly if a cognitive-behavioral therapy-based approach is used. The limited number of trials providing data amenable for meta-analysis for some outcomes and subgroups, the variability of interventions, study quality, and bias mean that it is not possible to draw more specific conclusions. Identifying what intervention qualities (such as number and type of protective factor) achieve the greatest positive effect per mental health problem outcome remains an important area for future research.nnnSYSTEMATIC REVIEW PROTOCOL AND REGISTRATIONnSystematic Review of Universal Resilience Interventions Targeting Child and Adolescent Mental Health in the School Setting; http://dx.doi.org/10.1186/s13643-015-0172-6; PROSPERO CRD42015025908.

Factors Associated With Concurrent Tobacco Smoking and Heavy Alcohol Consumption Within a Socioeconomically Disadvantaged Australian Sample

ABSTRACT Background: Tobacco use and heavy alcohol consumption occur more frequently in socioeconomically disadvantaged groups. Little is known about the sociodemographic and psychosocial factors associated with use of alcohol and tobacco in disadvantaged groups in comparison to low-risk users. Objectives: This study aimed to compare the characteristics of low-risk users with: disadvantaged smokers only; disadvantaged heavy drinkers only; and disadvantaged concurrent smokers and heavy drinkers. Methods: A cross-sectional survey of socioeconomically disadvantaged adult clients attending a community welfare agency assessed tobacco use, alcohol use, demographic, and psychosocial variables. Multivariable analysis using multinomial logistic regression was carried out. Results: The sample consisted of 835 participants; 40% (n = 331) were concurrent users, 31% were smokers only (n = 252), 11% were heavy drinkers only (n = 93), and 18% were low-risk users (n = 149). Compared with those who neither smoked nor consumed alcohol heavily, concurrent users were more likely to be younger, have only some contact with family, have more friends and family who were smokers, have no fixed home address, live alone, and have higher levels of financial stress. Most of these factors were shared by individuals who were smokers only. Factors associated with heavy drinkers only were frequent contact with family and having more friends and family who were smokers. Conclusion: Among those Australians who suffer severe economic hardship, being a concurrent smoker and heavy drinker appears to be associated with more isolated living conditions and financial stress but some contact with family.

Financial Stress and Smoking within a Large Sample of Socially Disadvantaged Australians

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

Hospital Smoke-Free Policy: Compliance, Enforcement, and Practices. A Staff Survey in Two Large Public Hospitals in Australia

Background: Smoke-free hospital policies are becoming increasingly common to promote good health and quit attempts among patients who smoke. This study aims to assess: staff perceived enforcement and compliance with smoke-free policy; the current provision of smoking cessation care; and the characteristics of staff most likely to report provision of care to patients. Methods: An online cross-sectional survey of medical, nursing, and allied staff from two Australian public hospitals was conducted. Staff report of: patient and staff compliance with smoke-free policy; perceived policy enforcement; the provision of the 5As for smoking cessation (Ask, Assess, Advise, Assist, and Arrange follow-up); and the provision of stop-smoking medication are described. Logistic regressions were used to determine respondent characteristics related to the provision of the 5As and stop-smoking medication use during hospital admission. Results: A total of 805 respondents participated. Self-reported enforcement of smoke-free policy was low (60.9%), together with compliance for both patients (12.9%) and staff (23.6%). The provision of smoking cessation care was variable, with the delivery of the 5As ranging from 74.7% (ask) to 18.1% (arrange follow-up). Medical staff (odds ratio (OR) = 2.09, CI = 1.13, 3.85, p = 0.018) and full time employees (OR = 2.03, CI = 1.06, 3.89, p = 0.033) were more likely to provide smoking cessation care always/most of the time. Stop-smoking medication provision decreased with increasing age of staff (OR = 0.98, CI = 0.96, 0.99, p = 0.008). Conclusions: Smoke-free policy enforcement and compliance and the provision of smoking cessation care remains low in hospitals. Efforts to improve smoking cessation delivery by clinical staff are warranted.

Reducing smoking reduces suicidality among individuals with psychosis: Complementary outcomes from a Healthy Lifestyles intervention study.

This study sought to explore the impact of smoking reduction on suicidality (suicide ideation and behaviour) among people with a psychotic disorder (n=235) who participated in a randomized trial of a healthy lifestyle intervention trial. Suicidality, measured by item -4 of the Brief Psychiatric Rating Scale (BPRS) was the main variable of interest. Measures were collected by research assistants blind to treatment allocation at baseline, at 15 weeks (mid-intervention) and 12 months after baseline. Mediation analysis, adjusted for confounders, was used to determine the relationship between smoking reduction and suicidality and to explore whether this was mediated through depression. At 12 months, smoking reduction was found to be significantly associated with suicidality change; an association was also seen between smoking reduction and depression and depression and suicidality. After adjusting for depression, the association between smoking reduction and suicidality was attenuated but remained statistically significant; the proportion of the total effect that was mediated through depression was 30%. There was no significant association between suicidality and treatment group (vs. controls) over time. Our study suggests that smoking interventions may have benefits over and above those for improved physical health, by reducing suicidal ideation in people with psychosis.

Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months

Objective: People living with psychotic disorders (schizophrenia spectrum and bipolar disorders) have high rates of cardiovascular disease risk behaviours, including smoking, physical inactivity and poor diet. We report cardiovascular disease risk, smoking cessation and other risk behaviour outcomes over 36 months following recruitment into a two-arm randomised controlled trial among smokers with psychotic disorders. Methods: Participants (Nu2009=u2009235) drawn from three sites were randomised to receive nicotine replacement therapy plus (1) a Healthy Lifestyles intervention delivered over approximately 9u2009months or (2) a largely telephone-delivered intervention (designed to control for nicotine replacement therapy provision, session frequency and other monitoring). The primary outcome variables were 10-year cardiovascular disease risk and smoking status, while the secondary outcomes included weekly physical activity, unhealthy eating, waist circumference, psychiatric symptomatology, depression and global functioning. Results: Significant reductions in cardiovascular disease risk and smoking were detected across the 36-month follow-up period in both intervention conditions, with no significant differences between conditions. One-quarter (25.5%) of participants reported reducing cigarettes per day by 50% or more at multiple post-treatment assessments; however, few (8.9%) managed to sustain this across the majority of time points. Changes in other health behaviours or lifestyle factors were modest; however, significant improvements in depression and global functioning were detected over time in both conditions. Participants experiencing worse ‘social discomfort’ at baseline (e.g. anxiety, mania, poor self-esteem and social disability) had on average significantly worse global functioning, lower scores on the 12-Item Short Form Health Survey physical scale and significantly greater waist circumference. Conclusion: Although the telephone-delivered intervention was designed as a comparison condition, it achieved excellent retention and comparable outcomes. Telephone-delivered smoking cessation support may potentially help to reduce smoking rates among people with psychotic disorders. Discomfort in social situations may also be a useful target for future health interventions, addressing confidence and social skills, and promoting social networks that reduce inactivity.

The ‘price signal’ for health care is loud and clear: A cross-sectional study of self-reported access to health care by disadvantaged Australians

Objective: To describe self‐reported inability to access health care and factors associated with lack of access among a socioeconomically disadvantaged group.

What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross‐sectional survey of use of cessation aids and quitting approach

INTRODUCTION AND AIMSnThis study aimed to compare current and ex-smokers sociodemographic and psychosocial characteristics, use of cessation aids and abrupt versus gradual quitting approaches.nnnDESIGN AND METHODSnA cross-sectional survey of financially disadvantaged adults attending a community service organisation was conducted in New South Wales, Australia, between February 2012 and December 2013. Sociodemographic and psychosocial factors, use of cessation aids and gradual versus abrupt quit approach were assessed. χ2 tests and logistic regression compared characteristics of current and ex-smokers.nnnRESULTSnOf 905 individuals who completed the survey, 639 (71%) were current smokers and 107 (12%) were ex-smokers. Ex-smokers were older [odds ratio (OR)xa0=xa01.03, 95% confidence interval (CI)xa0=xa01.01, 1.05], had higher odds of being female (ORxa0=xa01.67, 95% CIxa0=xa01.06, 2.65), lower odds of being financially stressed (ORxa0=xa00.87, 95% CIxa0=xa00.76, 0.99), lower odds of anxiety and depression symptoms (ORxa0=xa00.91, 95% CIxa0=xa00.84, 0.98) and lower odds of having friends and family who were smokers (ORs ranged from 0.30-0.43). Ex-smokers had lower odds of using cessation aids and higher odds of reporting abrupt quitting during their last quit attempt (ORxa0=xa04.48, 95% CIxa0=xa02.66, 7.54).nnnCONCLUSIONSnLower levels of disadvantage, less smoking in social networks, less use of cessation aids and abrupt (vs. gradual) quitting approaches were associated with being an ex-smoker. Lower use of evidence based methods to quit by disadvantaged ex-smokers requires further exploration. [Twyman L, Bonevski B, Paul C, Bryant J, West R, Siahpush M, Deste C, Oldmeadow C, Palazzi K. What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross-sectional survey of use of cessation aids and quitting approach. Drug Alcohol Rev 2017;00:000-000].

Smoking cessation care provision in Australian alcohol and other drug treatment services: A cross-sectional survey of staff self-reported practices

INTRODUCTIONnClinical practice guidelines recommend alcohol and other drug (AOD) services assess clients smoking status and offer smoking cessation care (SCC) to all smokers. The aim of this study was to examine Australian AOD program staff report of recommended SCC practices: assessment and recording of smoking status; and the provision of 9 types of SCC. The study also assessed how the decision to provide SCC is made and the AOD program service and AOD staff characteristics associated with the provision of SCC.nnnMETHODSnBetween July-October 2014, treatment staff from 31 Australian AOD services participated in an online cross-sectional survey. In addition, a site contact at each service was interviewed to gather service related data.nnnRESULTSnOverall, 362 AOD program staff participated (response rate=57%) and 62% estimated that client smoking status was recorded for the majority or all of their clients. About a third (33%) reported that they always provide verbal advice to their clients to quit smoking, 18% always offered free or subsidized NRT and 16% always followed-up to check on client quit progress. Thirty percent reported that the decision to provide SCC was made on a client by client basis and 26% offered SCC only when the client requested assistance. Government-managed services, age and gender of AOD program staff were significantly associated with the provision of SCC.nnnCONCLUSIONnMost AOD program staff report that smoking status is recorded for the majority of their clients however, the frequency with which SCC practices are delivered is low and the decision to provide care is arbitrary.