Evidence-practice gaps for Australian General Practitioners (GP) in assisting pregnant women to quit

Background: Smoking prevalence among Indigenous pregnant women is high at 49%. Evidence-based smoking cessation interventions have not been effectively translated into the maternal Indigenous context. Aims: To explore GPs' knowledge, attitudes and practices of managing smoking in pregnant women. Methods: A random sample of 500 members of the RACGP National Faculty of Aboriginal and Torres Strait Islander Health were invited to an on-line survey. Inclusion criteria were GPs who consult with pregnant women. The response rate was low at 8% (N = 42), however alternative recruitment is ongoing. Results: One-third of the sample worked in Indigenous organisations; 62% of respondents were women. Most GPs (81%) always asked and gave brief advice about smoking in pregnancy. Less GPs (62%) always provided cessation support, assessed dependence (55%), discussed the psychosocial context of smoking (33%), followed up within 2 weeks (14%); 5% referred to the Quitline. Only 21% always recommended/prescribed nicotine replacement therapy (NRT), despite 93% agreeing that using NRT in pregnancy was safer than smoking; 71% believed NRT was moderately effective, and 69% were confident to prescribe NRT. More GPs in Indigenous organisations, compared to mainstream, agreed that discussing smoking benefits their relationship with pregnant clients (p < 0.05). Discussing psychosocial contexts was positively associated with prescribing NRT (p < 0.05). Only 10% GPs trained in smoking cessation for pregnancy; 83% agreed training was warranted, over two-thirds agreed access to oral NRT should be improved. Conclusions: Smoking cessation is a high priority for cancer prevention. NRT can be offered to pregnant smokers unable to quit. Low levels of assisted quitting may relate to scarcity of training for pregnancy, and policies governing access. Caution is advised due to small sample size. Translational research aspect: Training GPs in smoking cessation for pregnant women, and improving NRT access, may progress T2/3 translation of evidence-based methods for smokers in high prevalence groups

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

Smoking cessation intervention delivered by social service organisations for a diverse population of Australian disadvantaged smokers: A pragmatic randomised controlled trial

OBJECTIVES There remains a need to identify effective smoking cessation interventions in severely disadvantaged populations. This trial aimed to examine the effectiveness of an intervention (Call it Quits) developed to promote smoking cessation and delivered by community social service case-workers. METHODS Call it Quits was a pragmatic, parallel randomised trial of a case-worker delivered smoking cessation intervention conducted in a non-government community social service organisation in New South Wales (NSW), Australia. Adult smokers requiring financial assistance were randomly assigned to the five-session Call it Quits intervention or usual care control group. Of the 618 eligible individuals, 300 were randomised to the intervention group, of whom 187 (62%) consented and 318 were randomised to the control group, of whom 244 (77%) consented, resulting in 431 participants. The primary outcome measure was self-reported continuous abstinence up to 6-month follow-up with biochemical verification. Primary analysis was performed using all the available data from participants under the assumption the data is missing completely at random, followed by sensitivity analyses. RESULTS No statistically significant differences in the primary outcome were found (1.4% in the control group versus 1.0% in the intervention group, OR = 0.77, p = 0.828). CONCLUSIONS A multi-component smoking cessation intervention delivering motivational interviewing-based counselling and free NRT by a trained case-worker within a community social service setting was not effective at achieving abstinence in a highly disadvantaged sample of smokers but increased attempts to stop and led to a reduction in number of cigarettes smoked daily.This study was funded by the National Health and Medical ResearchCouncil (NHMRC) of Australia (631055

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

Learning and action for gender-transformative climate-smart agriculture

This paper reports on a networking meeting of the CGIAR Research Program on Climate Change, Agriculture and Food Security (CCAFS) Gender and Social Inclusion (GSI) Flagship held at the university of Canberra, Australia on 1-2 April 2019. The meeting helped to identify opportunities for gender-transformative, climate-smart agriculture (CSA) through knowledge sharing and next steps for CCAFS Phase Two. Researchers involved in gender and social inclusion working across CCAFS reviewed the existing knowledge base, noted key gaps, and began the process of identifying future research questions and themes

Effect of natalizumab on disease progression in secondary progressive multiple sclerosis (ASCEND). a phase 3, randomised, double-blind, placebo-controlled trial with an open-label extension

Background: Although several disease-modifying treatments are available for relapsing multiple sclerosis, treatment effects have been more modest in progressive multiple sclerosis and have been observed particularly in actively relapsing subgroups or those with lesion activity on imaging. We sought to assess whether natalizumab slows disease progression in secondary progressive multiple sclerosis, independent of relapses. Methods: ASCEND was a phase 3, randomised, double-blind, placebo-controlled trial (part 1) with an optional 2 year open-label extension (part 2). Enrolled patients aged 18–58 years were natalizumab-naive and had secondary progressive multiple sclerosis for 2 years or more, disability progression unrelated to relapses in the previous year, and Expanded Disability Status Scale (EDSS) scores of 3·0–6·5. In part 1, patients from 163 sites in 17 countries were randomly assigned (1:1) to receive 300 mg intravenous natalizumab or placebo every 4 weeks for 2 years. Patients were stratified by site and by EDSS score (3·0–5·5 vs 6·0–6·5). Patients completing part 1 could enrol in part 2, in which all patients received natalizumab every 4 weeks until the end of the study. Throughout both parts, patients and staff were masked to the treatment received in part 1. The primary outcome in part 1 was the proportion of patients with sustained disability progression, assessed by one or more of three measures: the EDSS, Timed 25-Foot Walk (T25FW), and 9-Hole Peg Test (9HPT). The primary outcome in part 2 was the incidence of adverse events and serious adverse events. Efficacy and safety analyses were done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01416181. Findings: Between Sept 13, 2011, and July 16, 2015, 889 patients were randomly assigned (n=440 to the natalizumab group, n=449 to the placebo group). In part 1, 195 (44%) of 439 natalizumab-treated patients and 214 (48%) of 448 placebo-treated patients had confirmed disability progression (odds ratio [OR] 0·86; 95% CI 0·66–1·13; p=0·287). No treatment effect was observed on the EDSS (OR 1·06, 95% CI 0·74–1·53; nominal p=0·753) or the T25FW (0·98, 0·74–1·30; nominal p=0·914) components of the primary outcome. However, natalizumab treatment reduced 9HPT progression (OR 0·56, 95% CI 0·40–0·80; nominal p=0·001). In part 1, 100 (22%) placebo-treated and 90 (20%) natalizumab-treated patients had serious adverse events. In part 2, 291 natalizumab-continuing patients and 274 natalizumab-naive patients received natalizumab (median follow-up 160 weeks [range 108–221]). Serious adverse events occurred in 39 (13%) patients continuing natalizumab and in 24 (9%) patients initiating natalizumab. Two deaths occurred in part 1, neither of which was considered related to study treatment. No progressive multifocal leukoencephalopathy occurred. Interpretation: Natalizumab treatment for secondary progressive multiple sclerosis did not reduce progression on the primary multicomponent disability endpoint in part 1, but it did reduce progression on its upper-limb component. Longer-term trials are needed to assess whether treatment of secondary progressive multiple sclerosis might produce benefits on additional disability components. Funding: Biogen

Multiple and severe forms of socioeconomic disadvantage and tobacco use: exploring the factors that contribute to smoking amongst clients of community service organisations

Research Doctorate - Doctor of Philosophy (PhD)This thesis aimed to provide a detailed examination of the factors that affect smoking cessation within socioeconomically disadvantaged subgroups. Within this thesis socioeconomically disadvantaged groups were defined as groups who are more likely to experience multiple forms of social, material and financial disadvantage and who are less likely to be represented in epidemiological or population-wide studies. Six Papers are included in this thesis. Papers Two and Six are published and the remaining four papers are currently under editorial review. The results of two quantitative cross-sectional surveys carried out with clients of community service organisations formed the basis of this thesis. Clients of community service organisations represent a subgroup of the population who experience multiple forms of socioeconomic disadvantage. Paper One provided insight into the factors associated with being an ex-smoker versus a current smoker in a sample of individuals experiencing multiple and severe forms of disadvantage. To the authors' knowledge, no other study has examined the sociodemographic differences between disadvantaged current smokers and ex-smokers. Overall, ex-smokers appeared to exhibit less socioeconomic disadvantage relative than current smokers. Ex-smokers were also less likely to report using cessation aids and more likely to have abruptly quit smoking during their last quit attempt. The systematic review presented in Paper Twp systematically synthesised and compared the perceived barriers to smoking cessation across six disadvantaged groups: low income, Indigenous people, people with mental illness, people experiencing homelessness, prisoners and at risk youth. This paper provided new knowledge about the barriers to smoking cessation identified by disadvantaged smokers that were common across six selected socioeconomically disadvantaged groups. Smoking in order to manage stress, high prevalence and perceived acceptability of smoking and lack of support from health and other professionals are the three common barriers reported. The review also identified unique barriers that were specific to disadvantaged groups that should be considered when designing interventions for example, ceremonial and traditional significance of tobacco use in certain Indigenous communities. Paper Three extended the existing literature about the barriers to quitting by using a valid and reliable measure to identify the most important barriers to smoking cessation experienced within a socioeconomically disadvantaged sample of smokers. To date, no other study has clarified disadvantaged smokers’ perspectives on the prioritisation of barriers with a view to maximising smoking cessation success. Addiction, stress management and enjoyment were the top three barriers ranked as most important to address before cessation could occur. Barriers rated as large by more than a third of the sample included addiction, stress management, anxiety or depression management, relaxation, being unable to manage withdrawal symptoms and stressful life events. It is important to examine use of alcohol and tobacco in disadvantaged groups because use of both substances compounds the negative health effects associated use of either substance alone, and because heavy alcohol use compromises smokers’ ability to maintain smoking cessation. Paper Four extended the literature by examining the characteristics of individuals with different alcohol and tobacco use profiles compared to individuals who were neither heavy drinkers nor tobacco users. The comparison of different alcohol and tobacco use profiles with neither smokers nor heavy drinkers was a novel feature of this study and allowed the identification of potential factors that promote heavy drinking and tobacco use within disadvantaged groups. People who were concurrent heavy alcohol and tobacco users were more likely to experience more isolated living conditions and financial stress than individuals who were neither heavy alcohol users nor tobacco users. Similarly, examining the use of cannabis by disadvantaged smokers is important to consider, as cannabis use also compromises smokers’ ability to maintain smoking cessation. Paper Five provided new information on the prevalence of co-occurring cannabis and tobacco use in disadvantaged groups (including simultaneous use and the way cannabis may impact on cessation attempts. While there is a literature base surrounding the effects of cannabis use on smoking cessation, the literature provides limited guidance regarding the proposed mechanisms through which cannabis effects smoking cessation. Regular cannabis use was associated with decreased motivation to quit tobacco smoking and shortened length of previous quit attempt in a sample of socioeconomically disadvantaged smokers. Lower motivation to quit tobacco significantly mediated the association between regular cannabis use and shorter quit attempts. Paper Six explored the new and topical area of electronic nicotine delivery systems (ENDS; also known as electronic cigarettes) which may present opportunities for disadvantaged smokers interested in quitting or reducing their tobacco use. The Paper assessed awareness and use of electronic cigarettes amongst socioeconomically disadvantaged smokers in Australia, where electronic cigarettes containing nicotine are restricted. At the time of publication, only two other studies had assessed electronic cigarette use in disadvantaged groups in high income countries, and neither of these studies were carried out in Australia. Levels of awareness and use were comparable to levels in the Australian general population. Higher motivation to quit tobacco and use of e-cigarettes in the past 12 months is associated with perceiving e-cigarettes as effective aids to quit smoking and as a safer product compared to traditional cigarettes. In summary, this thesis provided new knowledge of the factors that affect smoking cessation within a subgroup of the population (clients of CSOs) who experience multiple and severe forms of socioeconomic disadvantage. The findings within this thesis suggest that there are multiple influences that affect smoking cessation that need to be addressed through individual and broader community and social network interventions. These include high levels of social and economic disadvantage, low levels of use of evidence based methods to quit, multiple and severe barriers to cessation at the individual, community and socio-economic level, and high levels of concurrent risky alcohol use and cannabis use. This thesis highlights the complexity of addressing smoking and cessation and the fundamental requirements for interventions to effectively aid quitting in groups experiencing multiple and severe forms of disadvantage

Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth. Design: A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups. Data sources: MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014. Study selection: Studies that provided either qualitative or quantitative (ie, longitudinal, crosssectional or cohort surveys) descriptions of selfreported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included. Data extraction: Two authors independently assessed studies for inclusion and extracted data. Results: 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco). Conclusions: Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social networklevel interventions are priority areas for future smoking cessation interventions within vulnerable group

Electronic cigarette use in New South Wales, Australia: reasons for use, place of purchase and use in enclosed and outdoor places

Abstract Objective: To monitor patterns of use of e‐cigarettes to understand their potential impact on the New South Wales (NSW) population in Australia. Methods: A cross‐sectional online survey was carried out with a sample of adults in NSW in February 2016. Ever and past 30‐day use of e‐cigarettes, reasons for use, place of purchase and use within outdoor and enclosed public places were assessed along with sociodemographic characteristics. Results: Ever and past 30‐day use was reported by 13% and 4% of the sample, respectively. More than one‐third of participants did not purchase their own e‐cigarette (36.3%). The most frequently reported reason for using an e‐cigarette for smokers and ex‐smokers was to help quit smoking (45.3% and 44.7%, respectively) while for non‐smokers it was novelty (40%). E‐cigarettes were most commonly used at home (59.4%), in outdoor dining areas (36.8%) and in the workplace (27.8%). Conclusions: E‐cigarettes are being used by a small percentage of the NSW population. Reasons for e‐cigarette use varied with smoking status. Different sociodemographic characteristics were associated with ever and past 30‐day use of e‐cigarettes. E‐cigarettes are being used in areas that are covered by smoke‐free legislation. Implications for public health: Given e‐cigarettes are being used in smoke‐free areas, policy‐makers could take a precautionary approach by including e‐cigarette use under smoke‐free legislation

Addressing smoking and other health risk behaviours using a novel telephone-delivered intervention for homeless people: a proof-of-concept study

Introduction and Aims: Despite substantial health disadvantage, few intervention studies have examined ways to deliver smoking cessation support to homeless people. This proof-of-concept study explored the feasibility and acceptability of a novel, low-cost, telephone-delivered program. Design and Methods: Clients aged over 18 years, English-speaking and currently receiving accommodation support from a homelessness outreach centre were invited to participate in a ‘Phone for Health’ program. Six sessions conducted once per week provided participants with personalised counselling about smoking cessation or reduction, as well as fruit and vegetable consumption, alcohol use, physical activity and sun protection. Both clients and staff completed follow-up quantitative surveys, and clients completed qualitative interviews. Results: Of 14 eligible participants, 12 consented to taking part and completed baseline measures, 10 commenced the telephone intervention and six completed the intervention program. Average length of telephone sessions was 17.8 min and participants completed an average of 3.8 sessions. Findings suggested high acceptability with most participants reporting that the Phone for Health program helped them meet their smoking reduction goals, and was convenient, useful and practical. Most participants reported making changes to their health risk behaviours as a result of taking part in the program. Discussion and Conclusions: Telephone delivery of the smoking cessation and other health behaviours intervention was acceptable and feasible. The results provide pragmatic lessons for the development of future health research and practice with an underserved population markedly difficult to reach and engage