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

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

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

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 &lt;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 &lt; 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

An exploration of socioeconomically disadvantaged smokers’ responses to three tobacco control strategies

Research Doctorate - Doctor of Philosophy (PhD)Although coordinated tobacco control approaches have been successful in reducing population prevalence rates of smoking, tobacco continues to account for significant morbidity and mortality. There also persists an inverse relationship between socioeconomic status and smoking prevalence that is evident both within and between countries. In Australia smoking rates are disproportionately high among groups who experience multiple levels of social and economic disadvantage such as those with low-income, indigenous populations, the long-term unemployed, individuals who are homeless and those with a mental illness. Limited research has assessed the impact of tobacco control interventions among highly socioeconomically disadvantaged groups with high smoking rates. The aim of this thesis was to explore how socioeconomically disadvantaged smokers in Australia respond to and engage with three tobacco control measures (mass media campaigns, plain packaging and health warning labels, and price). Participants were clients accessing non-government social and community service organisations for the provision of crisis aid and social and financial welfare assistance. Paper one “Anti-tobacco mass media and socially disadvantaged groups: a systematic and methodological review” presents the results of a literature review examining evidence of the differential effectiveness of mainstream and targeted mass media campaigns according to socio-demographic group. Findings varied across studies and outcome measures. While socioeconomically disadvantaged smokers may be less likely to recall general population campaigns compared to more advantaged groups, they may be equally likely to perceive these campaigns as effective and to quit in response. Overall, there is a lack of methodologically rigorous research investigating the effectiveness of anti-tobacco mass media campaigns, particularly among highly socioeconomically disadvantaged groups. It appears that some mainstream campaigns have the potential to be effective among socioeconomically disadvantaged smokers, however more research is needed. Paper two “What type of anti-smoking advertisement is perceived as more effective? An experimental study with a sample of Australian socially disadvantaged welfare recipients” evaluated responses to key anti-smoking message types (‘why-to-quit’ and ‘how-to-quit’ messages) among highly socioeconomically disadvantaged smokers (n = 354). The influence of nicotine dependence and cessation cognitions on ratings of message effectiveness was also assessed. To effectively promote cessation among socioeconomically disadvantaged smokers, mass media campaigns should include a high rotation of ‘why-to-quit’ television advertisements featuring negative emotive content and graphic imagery. Socioeconomically disadvantaged smokers reported high interest in quitting, but had limited quit success. Research on ways to improve the ‘how-to-quit’ message to capitalise on quit interest, motivate quit attempts and support cessation among socioeconomically disadvantaged groups with high smoking rates is needed. Paper three “Tobacco health warning messages on plain cigarette packs and in television campaigns: A qualitative study with Australian socioeconomically disadvantaged smokers” describes a qualitative study using six focus groups to explore how socioeconomically disadvantaged smokers engage with health-risk and cessation-benefit messages communicated via mass media campaigns and cigarette pack health warning labels. Some tobacco warning messages may not be resonating with disadvantaged smokers. Participants reported message avoidance behaviours, self-exempting beliefs towards warning message content and considered themselves to be desensitised to tobacco-related health warnings. Warning messaging should continue to use emotive content and address false beliefs about tobacco health-effects, but might also explore featuring more immediately relatable health concerns and providing more practical cessation advice. Discussions also indicated cigarette plain packaging negatively impacted on product perceptions and experience. Paper four “Socioeconomically disadvantaged smokers’ ratings of plain and branded cigarette packaging: an experimental study” tested the potential impact of cigarette plain packaging among socioeconomically disadvantaged smokers (n=354) prior to policy implementation in Australia. The experimental quantitative study used computer touchscreen survey methodology. Plain cigarette packs stripped of branding elements and featuring larger health warning labels were associated with reduced positive brand appeal and purchase intentions. This is the first study of its type providing evidence of the potential effectiveness of cigarette plain packaging policy among disadvantaged smokers. Paper five “Paying the price: A cross-sectional survey of Australian socioeconomically disadvantaged smokers’ responses to hypothetical cigarette price rises” assessed the use of strategies to minimise the impact of cigarette price rises across two hypothetical price rise scenarios, and measured the possible influence of financial stress. Consistent intended use of price-minimisation strategies to manage smoking costs was reported, and financial stress appeared to have little effect. Larger cigarette price increases (i.e. 20%) are significantly more likely to motivate smokers to consider quitting compared with smaller price rises (i.e. 10%). Smokers who indicated they would not change their smoking behaviour in response to price rises had heavy nicotine dependence, large weekly tobacco expenditures, and made fewer quit attempts in the past year indicating they may require additional cessation support. Paper six ““Cigarettes are priority”: A qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices” used qualitative interviews with socioeconomically disadvantaged smokers (n=20) to further examine the wider social and economic impacts of increasing cigarette taxes. To maintain smoking despite rising prices, socioeconomically disadvantaged smokers reduced household spending, consequently leading to further social and economic deprivation. Participants reported going without meals, substituting meal choices and not paying bills. The provision of additional assistance to smokers who may find it difficult to quit unaided, particularly during times of tobacco taxation increases, should be considered. In conclusion, the research contained within this thesis is the first in Australia to recruit highly socioeconomically disadvantaged smokers to examine responses to population-level tobacco control measures. The findings highlight ways current tobacco control interventions might be improved to increase effectiveness among socioeconomically disadvantaged smokers. Increasing the effectiveness of tobacco control strategies and adequately monitoring the impact of these interventions among highly disadvantaged groups with the highest smoking rates and documented poor quit success is pivotal to addressing the social gradient in smoking rates

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

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

Abstract 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 2nd 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 2nd 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

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