Hard-core Smokers, the Hardening Hypothesis and Harm Reduction: Implications for Australian Tobacco Control Policy

Background: The prevalence of cigarette smoking has decreased considerably in many developed countries over the past few decades. However, in Australia, the rate of the decrease has been slowing, and between 2013-2016, appeared to stall. This is important because cigarette smoking remains a major public health issue, and is – for example – the leading cause of cancer-related mortality in Australia. The slowing decline in smoking prevalence has prompted calls to address the interrelated issues of hardening and hard-core smoking. The hardening hypothesis proposes that, as smoking rates decline, the remaining smokers will become hard-core (i.e., more resistant to quitting). This group of hard-core smokers may require more tailored approaches to cessation and/or product-based tobacco harm reduction (THR). Although hardening and hard-core smoking are often discussed and investigated, the literature is plagued by inconsistencies in how these terms are defined and operationalised. As a result, many aspects of the nature of hardening and hard-core smoking remain unclear. Alternate nicotine delivery systems (ANDS), such as e-cigarettes, have been proposed as an option to achieve further reductions in smoking prevalence rates in Australia. This is because ANDS may support hard-core smokers to quit or (as a form of THR) transition smokers away from combustible cigarettes. The Australian regulatory environment for ANDS, together with a robust tobacco control environment, means that hard-core smoking and hardening research conducted in other countries may not be transferable to the Australian context. As such, there is a significant knowledge gap about the contemporary nature of hard-core smoking in Australia. This thesis aims to examine the existence and nature of hardening and hard-core smoking in an Australian context. In doing so, this thesis will also address important theoretical issues relating to the definitions and operationalisations of these concepts. This includes the application of the Precaution Adoption Process Model as a theoretical framework to understand hard-core smoking. This thesis is comprised of three empirical studies and two policy focused commentary papers which address the gaps in the literature to account for: i) contemporary evidence supporting claims of hardening amongst Australian and international smokers (Paper1); ii) identification of the extent of hard-core smoking rates in Australia (Paper 2); iii) an understanding of the characteristics of hard-core smokers (Papers 2 and 3); iv) exploration of a stage-based behaviour change model that may account for smokers who do not want to change their smoking behaviour (Paper 3); v) a review of the status of smoke-free spaces in Australia as a key component of non-product-based THR (Paper 4); and v) a review of Australian tobacco dependence treatment policy (Paper 5). Method: Paper 1 was a systematic review to identify and summarise studies on hard-core smoking and hardening to: i) determine the degree of variability in definitions of hard-core smoking and hardening; ii) assess the evidence for claims that smokers are becoming increasingly hardened; and iii) identify the determining characteristics of a hard-core smoker. We searched five electronic databases from 1970 to mid-April 2018 using the search term “smok* AND hard* AND (tobacco OR cigar* OR nicotin*)”. We included studies if they included a definition of hard-core smokers and/or hardening and provided a prevalence rate for hard-core smokers or empirical evidence for hardening. Paper 2 tested the hardening hypothesis by analysing the rates of hard-core smoking in the Australian smoking population between 2010 and 2016. Data were drawn from three waves of the National Drug Strategy Household Survey (NDSHS) in 2010, 2013 and 2016. Two different definitions were used to assess hard-core smoking to arrive at an upper and lower rate. Logistic regression models assessed hard-core smoker characteristics for both definitions of hard-core smoking. Paper 3 applied the Precaution Adoption Process Model (PAPM) to a community-based sample of smokers (n=336) to determine whether it provides a useful approach to identifying hard-core smokers. Australian smokers were recruited through social media and an online data collection agency. Paper 4 and Paper 5 reviewed the status of smoke-free spaces and tobacco dependence treatment as key THR approaches in Australia and outlined the need for renewed focus on implementing comprehensive, robust and evidence-based tobacco control polices to reduce population level harm and drive cessation in the face of lobbying by industry for widespread availability of ANDS products. Results: Paper 1 indicated there is considerable variability in how hard-core smoking is defined and operationalised in the literature. This variability was associated with inconsistencies in reported prevalence rates of hard-core smoking. The three empirical papers indicated there was little evidence of a crisis of hard-core smokers posing a credible threat to achieving further smoking prevalence reductions in Australia. Paper 1 suggested that hardening was not evident in the general smoking population, although there was evidence of softening occurring in smoking populations. In Paper 2, the most inclusive definition of hard-core smoking (i.e. a smoker with no plan to quit) showed a significant decline in hard-core smoking between 2010 and 2016 (5.49%–4.85%). The prevalence of hard-core smoking using the most stringent definition (i.e. a current daily smoker of at least 15 cigarettes per day, aged 26 years or over, with no intention to quit, a lifetime consumption of at least 100 cigarettes, and no quit attempt in the past 12 months) did not change significantly between 2010 and 2016. In Paper 3, 11.9% of smokers were in Stage 4 of the PAPM – i.e. had decided not to quit. These smokers were more resistant to quitting and exhibited similar characteristics to hard-core smokers. Conclusions: The present thesis demonstrates that the Australian smoking population is not hardening, nor are Australian smokers becoming increasingly hard-core. As such, further reductions in smoking prevalence are achievable by further strengthening and funding a comprehensive approach to tobacco control. This should include improvements in the delivery of tobacco dependence treatment (TDT) to improve quit outcomes amongst the majority of Australian smokers who are motivated to quit. ANDS may be of benefit to some smokers who have been unable to quit using evidence-based combination pharmacotherapy and behavioural support. However, they may create population level harm if they increase rates of youth smoking

An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.<br /

Minimum wages and their role in the process and incentives to bargain

The study is based on four sources of data: (a) a survey of over 11,500 non-public sector organisations, (b) quantitative analysis of over 25,000 enterprise agreements, (c) qualitative analysis of 91 strategically selected agreements; and (d) 20 workplace case studies. Key findings (indicative) Organisations commonly used a number of pay-setting arrangements for their employees, with individual arrangements (at 65 per cent of organisations) and award based arrangements (52 per cent) the most common. The quantitative analysis of enterprise agreements found that that there may be a positive association between wage increases in enterprise agreements and Annual Wage Review increases. This was particularly the case for industries with higher proportions of agreements paying low wage increases and with a large number of award-reliant employees. The qualitative analysis of agreements identified the importance of distinguishing between agreements that are ‘award-reliant’, ‘slightly above award’ (i.e. pay modest over-awards) and ‘over-award’ (i.e. pay substantial amounts more than the award).&nbsp; External relativities (i.e. differences in pay for exemplar or reference classifications common across employers) were dispersed among all industries considered. Internal relativities within agreements were very similar to those in their related awards. The case studies found little direct impact of Annual Wage Review decisions on wage outcomes or pay-setting processes – they are best conceived as third order factors shaping both. Conclusion While the direct impact of Annual Wage Review decisions was perceived to be limited at the work sites studied, this is not the whole story. The analysis of agreements revealed that there may be positive significant associations between Annual Wage Review increases and agreement content. The workplace cases in general, and the relativities analysis in particular, revealed that awards profoundly shape wage outcomes and the wage determination process.&nbsp; In particular, the agreement and case study findings highlighted the importance of not conceiving the different pay-setting arrangements in mutually exclusive terms. If the Annual Wage Review increases examined are conceived as being part of an ongoing evolution of the award system, then their impact is better understood as being very significant, primarily because such increases are an integral part of labour standard regime that conditions workplace behaviour and shapes wage outcomes. This appears to be especially the case in those parts of the labour market paying below median wages

An examination of equal access in athletic programs throughout public high schools in the United States

The mission of the U.S. Department of Education is “to promote student achievement and preparation for global competitiveness by fostering educational excellence and ensuring equal access” (www.ed.gov).  As an extension of U.S. public education institutions, secondary afterschool programs involving physical activity are theoretically designed to enhance and support the educational mission of public schools.  Yet, due to the hyper-commodification of youth sports, “equal access” in sport and physical activity is becoming increasingly limited to parameters grounded in highly competitive environments reflecting broader sport trends in society.  An interesting paradox emerges in public school settings where the importance of physical activity for adolescents is also emphasized.  However, in reality, the majority of public tax dollars funding extracurricular opportunities to be physically active are only for those who are highly competitive, physically literate and have the financial means to assist in the funding of their sport experiences.  There are also issues related to gender in terms of who is being served.  Therefore, it is importance to examine how public resources relating to physical activity and health are being unequally allocated in the public school setting.

Is the Australian smoking population hardening?

Background The hardening hypothesis proposes that as smoking rates decline, the remaining smokers will become hardcore and resistant to quitting. This group of highly resistant quitters will potentially require more individualistic approaches to cessation and harm reduction. The harm reduction approach (specifically e-cigarettes) has been proposed as an option to address hardened Australian smokers. We tested the hardening hypothesis by analysing the rates of hardcore smoking in the Australian smoking population between 2010-2016. Methods Data were drawn from three waves of the National Drug Strategy Household Survey (NDSHS) in 2010, 2013 and 2016. Two different definitions were used to assess hardcore smoking to arrive at an upper and lower rate. Logistic regression assessed hardcore smoker characteristics for both definitions of hardcore smoker. Results The most inclusive definition of hardcore smoking (i.e., a smoker with no plan to quit) showed a significant decline in hardcore smoking between 2010 and 2016 (5.49% - 4.85%) In contrast, the prevalence of hardcore smoking using the most stringent definition (i.e., a current daily smoker of at least 15 cigarettes per day, aged 26 years or over, with no intention to quit, a lifetime consumption of at least 100 cigarettes, and no quit attempt in the past 12 months) did not change significantly between 2010 and 2016. Conclusion The observed trends in the prevalence of hardcore smokers (i.e., either stable or declining depending on the definition) suggest that the Australian smoking population is not hardening. These results do not support claims that remaining smokers are becoming hardcore

Clinical care of pregnant and postpartum women with COVID-19: Living recommendations from the National COVID-19 Clinical Evidence Taskforce

To date, 18 living recommendations for the clinical care of pregnant and postpartum women with COVID-19 have been issued by the National COVID-19 Clinical Evidence Taskforce. This includes recommendations on mode of birth, delayed umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, antenatal corticosteroids, angiotensin-converting enzyme inhibitors, disease-modifying treatments (including dexamethasone, remdesivir and hydroxychloroquine), venous thromboembolism prophylaxis and advanced respiratory support interventions (prone positioning and extracorporeal membrane oxygenation). Through continuous evidence surveillance, these living recommendations are updated in near real-time to ensure clinicians in Australia have reliable, evidence-based guidelines for clinical decision-making. Please visit https://covid19evidence.net.au/ for the latest recommendation updates

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

The trans-ancestral genomic architecture of glycemic traits

Glycemic traits are used to diagnose and monitor type 2 diabetes and cardiometabolic health. To date, most genetic studies of glycemic traits have focused on individuals of European ancestry. Here we aggregated genome-wide association studies comprising up to 281,416 individuals without diabetes (30% non-European ancestry) for whom fasting glucose, 2-h glucose after an oral glucose challenge, glycated hemoglobin and fasting insulin data were available. Trans-ancestry and single-ancestry meta-analyses identified 242 loci (99 novel; P < 5 x 10(-8)), 80% of which had no significant evidence of between-ancestry heterogeneity. Analyses restricted to individuals of European ancestry with equivalent sample size would have led to 24 fewer new loci. Compared with single-ancestry analyses, equivalent-sized trans-ancestry fine-mapping reduced the number of estimated variants in 99% credible sets by a median of 37.5%. Genomic-feature, gene-expression and gene-set analyses revealed distinct biological signatures for each trait, highlighting different underlying biological pathways. Our results increase our understanding of diabetes pathophysiology by using trans-ancestry studies for improved power and resolution. A trans-ancestry meta-analysis of GWAS of glycemic traits in up to 281,416 individuals identifies 99 novel loci, of which one quarter was found due to the multi-ancestry approach, which also improves fine-mapping of credible variant sets.Peer reviewe

A global experiment on motivating social distancing during the COVID-19 pandemic

Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges