Evaluation of the Bila Muuji Smoking Cessation Project

Evaluation of the Bila Muuji Smoking Cessation Project John Stephenson

August 2012

Summary The Bila Muuji Smoking Cessation Project (BMSCP) was one of a number of projects funded by the Indigenous Tobacco Control Initiative to promote smoke free messages, inform smokers of the dangers of smoking and assist them to quit smoking. The aim of the BMSCP is to improve the health and well being of Aboriginal people and reduce the prevalence of cigarette smoking in specific communities defined by access to Bila Muuji community controlled health services (ACCHS). The Project commenced in July 2010 and was completed on time in June 2012. Project infrastructure has been delivered as per the Project Plan: employment of a project manager and 2 clinicians; recruitment of smoking cessation advisers in most Bila Muuji ACCHSs; provision of training for all staff; development of appropriate interview questionnaires, client records and evaluation methodology; provision of regular clinics to all ACCHSs except when local flooding has prevented access e.g. to Bourke, Brewarrina and Walgett; purchase and distribution of sufficient and appropriate pharmacotherapy products;

Key Results and Features of the MBSCP

● There are an estimated 2280 adult Aboriginal smokers in the 9 participating communities on the assumption that 50% of adults are smokers and using 2006 Census population estimates.

● High level of commitment of Project staff to improving the health and welfare of Aboriginal people in ● ● ● ●

● ● ●

●

● ● ● ●

general and providing an accessible and supportive service in all ACCHSs. Recruitment of SCAs is optimal when the individual is: committed to the Program; passionate about the importance of quitting smoking; are given dedicated time to the Program; supported in the role by their Practice Manager and CEO; and, have capacity for initiative. A high level of training at the start of the Project has led to a high degree of clinical skill and confidence by the Project clinicians that translates into excellent on the job education and mentoring of SCAs. The clinicians are professionally connected to other cessation clinicians and the wider tobacco control network in Australia. High level of recruitment of adult smokers into the Program, for example the estimate in Dubbo is 9%; Orange 14%; Bourke 21%; Brewarrina 20%; Coonamble 29%; Dareton 35% and Balranald 50%. Typically clients commenced smoking in their middle teenage years and have been smoking on average for 20 + years. The Project has documented high levels of co-morbidity of diseases that are highly attributable to tobacco smoking as well as high levels of mental health and other drug use issues amongst participants in the Program. The proportion of smoke free homes was higher than expected with many additional participants intending to make their homes and vehicles smoke free. Smoking status is documented by the self reporting of number of cigarettes smoked per day and by the results of a respiratory CO (carbon monoxide) reading at regular intervals following commencement in the Program. Using client data for their most recent presentation, then for example 11 people have quit smoking in Bourke (22% of participants which is 5% of the estimated number of smokers); 41 people have quit in Dubbo (53% of participants which is 4.6% of the estimated number of smokers) and 27 people have quit in Coonamble (45% of participants which 13.4% of the estimated number of smokers. Of the estimated 2578 adult Aboriginal smokers in the project towns, 440 (17.1%) were recruited into the Program. The Project has documentation for 119 people who have quit smoking with the assistance of the Project. This represents 27% of those who attended at least one clinic and 4.6% of the total estimated number of smokers in the participating towns. This is a conservative estimate of the number of people who quit smoking. There is anecdotal evidence that additional participants also quit but for various reasons project staff were unable to verify their CO levels and self reported smoking status. Average CO readings and average number of cigarettes consumed per day were reduced in all communities. Personal stories about the social and health importance of quitting are provided in Appendix 3 and 4. Reasons given by participants in the Program for failed quit smoking attempts have been listed and document the burden of health, social and mobility issues endured by many participants. A survey of AMS CEOs, Practice Managers and Project staff indicated a very high level of support for the Program and a strong desire to continue the Program beyond the funding period. Suggestions for improving the service have been noted.

Bila Muuji Smoking Cessation Project

August 2012 Final Evaluation Report

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Introduction The Bila Muuji Smoking Cessation Project (BMSCP) was one of a number of projects funded by the Indigenous Tobacco Control Initiative to promote smoke free messages, inform smokers of the dangers of smoking and assist them to quit smoking. The aim of the BMSCP is to improve the health and well being of Aboriginal people and reduce the prevalence of cigarette smoking in specific communities defined by access to Bila Muuji community controlled health services (ACCHS). The project schedule sets out the objectives, outcomes and performance indicators for the project as outlined in Appendix 1. The following interim analysis is based on indigenous participants in the Program. A small number of non indigenous people were included in the project presumably because they either were clients of the local AMS or had an association with the local Indigenous community. Non Indigenous people have been excluded from the analysis. Population estimates for each location has been obtained from the NSW Department of Aboriginal Affairs using their Community Profiles based on the 2006 Census. Smoking prevalence rates are higher in the Greater Western AHS than NSW (NSW Population Health Survey, 2008) and for some gender/age groups, significantly so (95% CI). A 2004/05 report on tobacco smoking by Indigenous people (ABS: Tobacco Smoking – Indigenous and Torres Strait Islander people: A snapshot, 2004/05) based on a national health survey and social survey suggested that half the adult indigenous population were current daily smokers and that this proportion had been stable for the previous decade. Daily smoking rates were higher for men in remote areas and for younger adults compared to adults over 50 years of age. The report concluded that the rate of regular smoking by indigenous men was twice that of non-indigenous men (51% compared to 24%) and two and half times the rate of indigenous women compared to non-indigenous women (49% to 18%) across Australia. Population risk factor assessments were conducted in western NSW in the 1990s. Table 1 summarises the results (Andrews, B and Stephenson, J. Smoking and Health Report, Orana and Far West Region, 1993 Health Promotion Unit). The only prevalence rate under 50% was for males in Wellington. The national survey cited above suggests that prevalence rates may not have changed since these landmark studies in 1990.

Table 1: Indigenous Smoking Prevalence in Orana and Far West towns, 1989 to 1990 Male Female Town and Year

Wilcannia 1989 Wilcannia 1990 Collarenebri 1990 Warren 1990 Wellington 1990 Bourke 1990

No. in survey

No. of current smokers

Proportion of smokers (%)

No. in survey

No. of current smokers

Proportion of smokers (%)

111

80

71.4

98

74

75.5

84

54

64.3

75

56

74.5

39

22

56.4

40

21

62.5

20

15

75.0

22

14

63.6

25

12

48.0

43

31

72.1

76

42

55.2

107

56

52.3



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Project Description The Bila Muuji Smoking Cessation project commenced in July 2010 after the employment of Geoff du Toit as Project Manager and Judy Scolari Gibson and Melissa Romeo as clinicians. Local Smoking Cessation Advisers (SCAs) have been recruited and trained in most locations including: Bourke also covering Orange; Wellington; Dubbo; Coonamble and trainees in Balranald, Walgett and Brewarrina. All SCAs receive on the job training and some have attended one or more of the courses listed below. Their connection and acceptance in the their local community is their strongest attribute. The level of competency to perform as an independent SCA varies considerably between SCAs. A couple of SCAs have developed excellent knowledge, skills and competence in the delivery of this cessation program and in the opinion of the clinicians will be able to continue providing a high level of service with occasional clinical support and mentoring. The SCAs have played an essential role in the recruitment of smokers into the program and it is suggested that they could perform a vital role in smoking prevention and education initiatives. The two smoking cessation clinicians and Project Manager were fully occupied in delivering a clinical service to clients who booked into regularly held clinics in each participating town. Unfortunately widespread flooding in 2010 and 2011 interrupted the roll out of the program by temporarily preventing access to towns such as Brewarrina, Walgett and Goodooga. In addition to providing cessation clinics in Balranald and Dareton, the Project Manager initiated a school based education program in 6 public schools (years 4 to 6) and 1350 children. The Program also provided education at events such as WAMS 25th Anniversary, „Mums and Bubs Program, Men‟s‟ Health Nights and Men‟s‟ Health Pitstop events. An example of a partnership between the Program and the local community was provided in Balranald where negotiations with the Local Council led to a smoke free area in a children‟s play area and swimming pool. The Project Manager, Clinicians and some of the SCAs have attended several training courses including:

● 2010 Update Smoking Cessation course run by Renee Bittoun Assoc Prof Smoking Cessation ● ● ● ● ● ● ● ● ● ● ●

Clinic RPAH and University of Sydney Intensive Treatment Course, run by Rennae Bittoun in Dubbo Train the Trainer, Cancer Council, Queensland Smokecheck, Sydney University Health Evaluation, Flinders University, Adelaide Video conference training with Mind and Brain Institute, Sydney Action on Tobacco Control Conference, Brisbane Oceania Tobacco Conference, Darwin, 2010 Oceania Tobacco Brisbane 2011 NSW Intermediate Course in tobacco cessation Smoking Cessation Course, The Alfred Hospital, Melbourne One on one training provided by tobacco cessation clinicians for SCAs

Pharmacotherapy Products used by Bila Muuji Smoking Cessation Project Patches Total number of patches is 66,010 Nicabate 21mg Clear 3,040 14 day packs (total of 42,560 patches) Quitx 21mg opaque 1,030 7 day packs (total of 7,210 patches) Nicorette 15mg `16mg 16 hour 470 28 day packs (total of 13,160 patches) Nicotinell 21mg 130 28 day packs (total of 3,080 patches) Nicorette inhaler starter kits 860 Nicorette inhaler refills 1006 Nicorette 2mg microtabs 470 Nicorette 2mg gum 494 Nicorette 4mg gum 100 Nicabate 4mg microtabs 3312



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Results Balranald 1 person quit smoking which is 3% of participants and 3.7% of smokers. The Project has recruited 30 people into the Program in Balranald, of whom 17 are indigenous females and 10 are indigenous males. Table 2 indicates that 65% of estimated adult Indigenous females and 45% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 17 years for females and 15 years for males and the average number of years of smoking is 28 years for females and 20 years for males. On average, participants had tried to quit on at least 3 occasions prior to participating in the project and the desire to quit is ranked reasonably high ( 6 on a scale of 1 to 10). On average there were 3 smokers in their home and an impressive 14 (52%) lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 3 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. One person had quit smoking after 3 months in the Program, For those who leave the Program, the outcome is less clear; some may have stayed smokefree; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. The end of project analysis will attempt to capture data for all participants. Three (18%) of female and 6 (60%) of male participants identified as having a mental health issue and 11% of participants recorded a medical condition that could be attributed to tobacco use. Table 2: Project Population Data, Balranald, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 16 8 5 63%

Years of Age 35 - 49 21 11 3 29%

50+ 15 8 9 120%

Total 52 26 17 65%

20 10 5 50%

12 6 4 67%

15 8 1 13%

47 24 10 43%

Table 3: Project Outcomes, Balranald Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 22 18 0

22 21 0

Months in Program 3 months 6 months 13 21

12 months 15

1 6% 25

20


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Bourke 11 people quit smoking which is 22% of participants and 4.8% of smokers. The Project has recruited 53 people into the Program in Bourke, of whom 31 are indigenous females and 13 are indigenous males. Table 4 indicates that 23% of estimated adult Indigenous female smokers and 13% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 12 years for females and 12 years for males and the average number of years of smoking is 26 years for females and 29 years for males. On average participants had tried to quit on at least 3 occasions prior to participating in the project and the desire to quit is ranked very highly (8 on a scale of 1 to 10). On average there were 2 smokers in their home and an impressive 18 (67%) of females and 5 (38%) of males lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 5 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. 5 (13%) people had quit smoking after 3 months in the Program and 6 (15%) at 6 months of being on the Program. For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 5 (16%) of females and 6 (33%) of males were not smokers. 8 (26%) of female participants identified as having a mental health issue and 8 (26%) of females and 6 (33%) of male participants recorded a medical condition that could be attributed to tobacco use. Table 4: Project Population Data, Bourke, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

Years of Age 20 - 34 35 - 49 99 91 50 46 4 13 8 29 70 35 2 6

75 38 9 24

50+ 74 37 14 38

Total 264 132 31 23

57 29 7 25

202 101 18 18

Table 5: Project Outcomes, Bourke Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 16 15 0 0 23 22 0 0

Months in Program 3 months 6 months 8 5 2 1 5 3 16 10 7 6 4 22

12 months 11 2 4 13

8 5 3 17


6 8 4 22

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Brewarrina 11 people quit smoking which is 26% of participants and 5.3% of smokers. The Project has recruited 61 people into the Program in Brewarrina, of whom 28 are indigenous females and 15 are indigenous males. Table 6 indicates that 25% of estimated adult Indigenous females and 15% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 16 years for females and 18 years for males and the average number of years of smoking is 24 years for females and 20 years for males. On average participants had tried to quit on at least 1 occasion prior to participating in the project and the desire to quit is ranked highly ( 7 to 8 on a scale of 1 to 10). On average there were 2 to 3 smokers in their home and 29 (67%) lived in a smoke-free homes. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 7 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. Ten people had quit smoking after 3 months in the Program, 7 by 6 months and 5 by 12 months (some quitters at 6 months haven‟t been in the program long enough to record their smoking status at 12 months). Of those who have stayed in the Program, this represents 18% of female participants and 33% of males at 3 months, 7% (F) and 33% (M) at 6 months and 4% (F) and 27% (M) at 12 months. This is a very impressive outcome, for participants who stay in the Program. For those who leave the Program, the outcome is less clear; some may have stayed smokefree; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 4 (14%) females and 7 (47%) males were not smokers. About 12% of all participants recorded a mental health issue and 14% also recorded a tobacco related chronic health problem. Table 6: Project Population Data, Brewarrina, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 83 42 11 27

Years of Age 35 - 49 82 41 12 29

50+ 56 28 5 18

Total 221 111 28 25

64 32 7 22

75 38 4 11

56 28 4 14

195 98 15 15

Table 7: Project Outcomes, Brewarrina Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 18 17 0 0 23 22 0 0


12 months 12 10 1 4

7 1 5 33


2 0 4 27

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Coonamble: 27 people quit smoking which is 45% of participants and 13.4% of smokers. The Project has recruited 79 people into the Program in Coonamble, of whom 34 are indigenous females and 25 are indigenous males. Table 8 indicates that 30% of estimated adult Indigenous females and 28% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 15 years for females and 16 years for males and the average number of years of smoking is 26 years for females and 32 years for males. On average participants had tried to quit on at least 2 - 3 occasions prior to participating in the project and the desire to quit is ranked highly ( 7 - 8 on a scale of 1 to 10). On average there were 2 - 3 smokers in their home and only 8 (13%) lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 9 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. 21 people had quit smoking after 3 months in the Program which is an impressive 36% of participants. For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 15 (44%) of females and 12 (48%) of males were not smokers. 12 (34%) of female and 5 (20%) of male participants identified as having a mental health issue and 13 (37%) of females and 16 (64%) of male participants recorded a medical condition that could be attributed to tobacco use. Table 8: Project Population Data, Coonamble, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

Years of Age 20 - 34 35 - 49 93 67 47 34 9 14 19 42 58 29 5 17

60 30 5 17

50+ 63 32 11 35

Total 223 112 34 30

62 31 15 48

180 90 25 28

Table 9: Project Outcomes, Coonamble Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 25 21 0 0 21 26 0 0


12 months 12 2 7 21

6 2 9 36


12 0 3 12

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Dareton 2 people quit smoking which is 6% of participants and 2.1% of smokers. The Project has recruited 42 people into the Program in Dareton, of whom 11 are indigenous females and 25 are indigenous males. Table 10 indicates that 22% of estimated adult Indigenous females and 56% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 14 years for females and 17 years for males and the average number of years of smoking is 24 years for females and 22 years for males. On average participants had tried to quit on average 2 to 3 occasions prior to participating in the project and the desire to quit is ranked highly ( 7 to 8 on a scale of 1 to 10). 29 (56%) participants lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 11 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. There is evidence that two people have quit smoking after 3 months in the Program which represents 6% of recruits to the Program. However, the Program counsellor for Dareton indicates that 11 people have quit smoking. For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. 15 (42%) of all participants recorded a mental health issue and 12 (33%) also recorded a tobacco related chronic health problem Table 10: Project Population Data, Dareton, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 35 18 3 17

Years of Age 35 - 49 33 17 3 18

50+ 31 16 5 32

Total 99 50 11 22

24 13 9 72

44 22 8 36

20 10 8 80

89 45 25 56

Table 11: Project Outcomes, Dareton Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 25 12 0 0% 21 18 0 0%

Months in Program 3 months 6 months 16 8

4 0 2 8%

12 months

4


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Dubbo 41 people quit smoking which is 53% of participants and 4.6% of smokers. The Project has recruited 89 people into the Program in Dubbo, of whom 54 are indigenous females and 24 are indigenous males. Table 12 indicates that 11% of estimated adult Indigenous females and 6% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 17 years for females and 15 years for males and the average number of years of smoking is 25 years for females and 26 years for males. On average participants had tried to quit on at least 2 occasions prior to participating in the project and the desire to quit is ranked highly ( 8 on a scale of 1 to 10). On average there were 2 smokers in their home and only 12 (25%) lived in a smoke-free home. The average number of counselling sessions was 5. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 13 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. Two people entered the Program who had recently quit smoking but valued the positive reinforcement that the Program offered. 16 people had quit smoking after 3 months in the Program, 31 by 6 months and 27 by 12 months (some quitters at 6 months haven‟t been in the program long enough to record their smoking status at 12 months). Of those who have stayed in the Program, this represents 24% of female participants and 50% of males at 3 months, 62% (F) and 83% (M) at 6 months and 83% (F) and 100% (M) at 12 months. This is a very impressive outcome, for participants who stay in the Program. For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 29 (54%) of females and 12 (50%) of males were not smokers. 24 (44%) of female and 10 (59%) of male participants identified as having a mental health issue and 24% of male participants recorded a medical condition that could be attributed to tobacco use. Table 12: Project Population Data, Dubbo, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 407 204 19 9%

Years of Age 35 - 49 348 174 17 10%

50+ 222 111 18 16%

Total 977 489 54 11%

339 170 9 5%

289 145 6 4%

185 93 97 10%

813 407 24 6%

Table 13: Project Outcomes, Dubbo Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 21 29 1 2% 21 28 1 6%

Months in Program 3 months 6 months 10 7 9 6 10 21 24% 62% 9 9 6 50%

6 0.3 10 83%

12 months 3 3 19 83% 3 0 8 100%


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Orange 14 people quit smoking which is 27% of participants and 3.9% of smokers. The Project has recruited 81 people into the Program in Orange, of whom 25 are indigenous females and 27 are indigenous males. Table 14 indicates that 12% of estimated adult Indigenous females and 18% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 16 years for females and males and the average number of years of smoking is 27 years for females and 19 years for males. On average participants had tried to quit on 2 occasions prior to participating in the project and the desire to quit is ranked very highly (7 - 9 on a scale of 1 to 10). On average there were 2 smokers in their home and 15 (33%) lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 15 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. 17people had quit smoking after 3 months in the Program, 12 by 6 months and 9 by 12 months (some quitters at 6 months haven‟t been in the program long enough to record their smoking status at 12 months). Of those who have stayed in the Program, this represents 20% of female participants and 7% of males at 3 months, 32% (F) and 15% (M) at 6 months and 24% (F) and 11% (M) at 12 months. This is a very impressive outcome, for participants who stay in the Program . For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 9 (36%) of females and 5 (11%) of males were not smokers 14 (56%) of female and 9 (33%) of male participants identified as having a mental health issue and 11 (44%) of females and 2 (7%) of male participants recorded a medical condition that could be attributed to tobacco use. Table 14: Project Population Data, Orange, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 171 86 7 8

Years of Age 35 - 49 146 73 13 18

50+ 86 43 5 12

Total 403 202 25 12

143 72 14 20

113 57 10 18

50 25 3 12

306 153 27 18

Table 15: Project Outcomes, Orange Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 21 22 0 0 26 21 0 0


12 months 3 1 6 24

5 0 4 15


2 0 3 11

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Walgett 3 people quit smoking which is 13% of participants and 1.3% of smokers. The Project has recruited 34 people into the Program in Walgett, of whom 14 are indigenous females and 10 are indigenous males. Table 16 indicates that 11% of estimated adult Indigenous females and 9% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 19 years for females and 13 years for males (in large part due to the recruitment of under 20 year olds into the Program) and the average number of years of smoking is 19 years for females and 11 years for males. On average participants had tried to quit on one occasion prior to participating in the project and the desire to quit is ranked highly ( 7 - 8 on a scale of 1 to 10). On average there were 2 smokers in their home.. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 17 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. 3 people had quit smoking after 3 months in the Program which is 13% of participants. For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. 3 (25%) of female and 4 (40%) of male participants identified as having a mental health issue and 5 (42%) of females and 1 (10%) male participant recorded a medical condition that could be attributed to tobacco use. Table 16: Project Population Data, Walgett, Indigenous Female & Male, 2011/12 Years of Age 20 - 34 35 - 49 95 81 48 41 7 6 15 15

50+ 70 35 1 3

Total 246 123 14 11

83 42 2 5

64 32 1 3

231 116 10 9

Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate 84 Est no. of smokers (50% of pop) 42 Recruits to Project 7 Est % of Smokers 17* Includes some recruits who were under 20 years of age.

Table 17: Project Outcomes, Walgett Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 12 16 0 0 9 21 0

Months in Program 3 months 6 months 2 2 2 14

12 months 2

2 14

1 7

0

0

2 1 10


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Wellington 9 people quit smoking which is 11% of participants and 3.0% of smokers. The Project has recruited 120 people into the Program in Wellington, of whom 51 are indigenous females and 29 are indigenous males. Table 18 indicates that 32% of estimated adult Indigenous females and 22% of indigenous male smokers have been recruited into the Project. The average age at commencement of smoking was 20 years for females and 18 years for males and the average number of years of smoking is 26 years for females and 22 years for males. On average participants had tried to quit on 2 occasions prior to participating in the project and the desire to quit is ranked highly (6 - 8 on a scale of 1 to 10). On average there were 2 smokers in their home and 17 (21%) lived in a smoke-free home. For a few, a single counselling session is sufficient to motive them to quit smoking. Others attended one or more sessions and then dropped out of the program for a variety of reasons such as: moving to another town; medical emergencies for themselves or family members; loss of interest in quitting at this time and a collection of social reasons. Table 19 presents a summary of results for participants at several intervals. Data is incomplete for some participants reflecting the ongoing recruitment of new participants and the difficulty of recording information for people who leave the program. 9 people had quit smoking after 3 months in the Program, 6 by 6 months and 2 by 12 months (some quitters at 6 months haven‟t been in the program long enough to record their smoking status at 12 months). Of those who have stayed in the Program, this represents 12% of female participants and 10% of males at 3 months, 6% (F) and 10% (M) at 6 months and 4% (F) and 0% (M) at 12 months. However, the Program smoking cessation counsellor for Wellington indicates that 14 people have quit smoking For those who leave the Program, the outcome is less clear; some may have stayed smoke-free; others will rejoin the Program for another assisted attempt to quit smoking; and, others for all sorts of health and social reasons are unable to commit to the Program and are likely to remain smokers. Another way of analysing the data is to consider the last available smoking status recording: 7 (14%) of females and 2 (7%) of males were not smokers 8 (16%) of female and 4 (14%) of male participants identified as having a mental health issue and 12 (24%) of females and 3 (10%) of male participants recorded a medical condition that could be attributed to tobacco use. Table 18: Project Population Data, Wellington, Indigenous Female & Male, 2011/12 Female 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers Male 2006 population estimate Est no. of smokers (50% of pop) Recruits to Project Est % of Smokers

20 - 34 121 61 14 23

Years of Age 35 - 49 112 56 16 29

50+ 87 44 21 48

Total 320 160 51 32

93 47 13 28

80 40 7 18

93 47 9 19

266 133 29 22

Table 19: Project Outcomes, Wellington Indigenous Female & Male, 2011/12 Female Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking Male Avg CO (ppm) Avg No Cigs per day No of quitters % current participants who quit smoking


Start 20 21 0 0 23 23 0 0


12 months 3 0 2 4

1 3 3 10


6 2 0 0

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Survey of CEOs, Practice Managers and Project Staff A survey was undertaken in June 2012 to gauge the responses of Aboriginal Health Service CEOs, Practice Managers and Project staff to a list of questions about the planning, implementation and effectiveness of the project. The survey form is provided in Appendix 2. 16 responses were received and the responses to Questions 1 to 8 are provided in Table 20. The responses indicate a very strong support for the importance of addressing tobacco use as a key ingredient for improving the health of Aboriginal people. 16 (100% of respondees agree or strongly agree with this premise. The adequacy of community consultation, planning and communication about the project was rated as good (Question 2 and 3). The number and quality of clinics provided in local AMS is very highly rated with 13 (82% ) of responses „strongly agreeing‟ (Question 4). The respondees recognise the commitment, professionalism and compassion of the Project staff who have encouraged trust amongst AMS staff and clients. This means that clients have been willing participants in the program. The importance of free quit products such as patches, microtabs and inhalers is acknowledged as is the provision of weekly clinics. Although some respondees thought there should have been more clinics and better promotion of the service. Most agree that the clinics are an excellent example of a well run program that is culturally appropriate and integrated into a bigger picture of trying to reduce the burden of preventable chronic illness that is widespread in Aboriginal communities. Similarly 12 (75%) of respondees strongly agreed that the education, training and support of local Smoking Cessation Advisors was excellent (Question 5). This is very important for the sustainability of the program and its acceptance and use in local communities. This is reinforced by AMS staff attending the clinics and progressing to quitting smoking. Acceptance and support for the project is strong (Question 6), however, there is less confidence that the program and clinics will continue beyond the project‟s life. 12 (75%) of respondees agree or strongly agree that the clinics will continue after project funding ceases in 2012. Respondees qualified their intentions and noted in „Comments‟ below that the clinics future will depend on funding availability. There is the suggestion that the clinics in some AMS will be integrated into their usual services. Question 8 indicates support for analysis of extra data that has been collected by the project that relates to issues associated with tobacco use. The data could be collected and analysed over time to gauge knowledge, attitudes and behaviour associated with tobacco use. For example smoking inside homes and cars, support for plain packaging of tobacco products and personal price elasticity. Table 20: Survey of AHS CEOs, Practice Managers and Project Staff June 2012 Question 1.Tobacco control and quit smoking are key strategies to improving the health of Aboriginal people in your community. 2. You and your community were adequately consulted during the planning of this project 3. You have received an appropriate level of communication about the progress of the project over the last 2 years 4. The number and quality of clinics in your health service provided by the Project has been excellent. 5. The education, training and support for local Smoking Cessation Advisors (SCAs) has been excellent. 6. Acceptance and support for the Project clinics amongst your staff and in your community has been excellent. 7. You intend to continue the Smoking Cessation clinics after the project funding ceases in July 2012. 8. The project collected data from clinic participants on issues such as: residence in smoke free homes; use of smoke free cars; support for plain packaging of cigarettes; and, likely impact on tobacco use of cigarette price increases. Should this data be analysed and reported by the project?


Strongly Disagree /Disagree

Neutral

Agree

Strongly Agree

0

0

1

15

0

1

8

7

0

1

5

10

0

0

3

13

0

0

4

12

0

0

5

11

0

2

3

9

0

1

5

10


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Comments ● ● ● ●

● ● ● ●

Q7 – “if funding available” Q8 – “reports on data could be used to target particular issues as a public health initiative” Q7 – “depends on funding” “The Bila Muuji Smoking Cessation Project has been fully developed and delivered, as per project plan agreed to by BM Executive, Indigenous Tobacco Control Initiative (ITCI) and DoHA. This is an evidence based project with expert external evaluation, that is ground-breaking in tobacco control, and will provide evidence statistics (the first known in Australia for Aboriginal people) for information and direction, to support other projects that tackle the “Harmful Effects of Smoking” to Aboriginal peoples health and longevity. The BMSCP has established with certainty that most Aboriginal smokers want to quit, and with counselling and clinical advice have made definite healthy changes to their daily lives, and are fully aware of the consequences that can be expected. Many have quit completely, some are on harm-reduction (e. g. down from 40 cigarettes a day to 4 per day), others smoking outside of their homes, and quitting to smoke during pregnancy. The BMSCP clinics have had many patients who were very sick (some have since passed away), many who were not as ill but wanting to quit after realising the danger, and some “having a go” which is a great step forward, as many smokers need more than a singular attempt to quit. The BMSCP clinic‟s were exposed to a vast amount of patient confidential issues, which included most of the issues faced by families in Aboriginal communities that required help from the medical system. As the patients became familiar with the BMSCP clinicians through attending smoking clinic, they spoke of their confidential issues, and help was sought for the patient by the clinicians through services available at the ACCHS to which the patients were referred. The BMSCP also put a new buzz into the waiting rooms at ACCHS locations with people chatting and discussing with their community while waiting for their appointment. The BMSCP worked with Doctors, Nurses, and Aboriginal Health Workers, to further inform the staff of smoking cessation methodologies, and patient treatment. The BMSCP also extended to public health promotion, partnering with councils (joint initiatives to provide no-smoking signage at smoking points) schools (developed “Famous Camus” and presented to 1250 year 4/5/6 students in a pilot program), and other health service areas such as Mum‟s and Bub‟s, men‟s sexual Health, women‟s health programs, dietician meeting, maternal health educators, oral health initiatives, mental heath programs etc. The BMSCP enjoys great community support, and through the support for the clinic the message has been carried to the extended community, BMSCP also developed “Medicine Bags” multi-purpose cloth bags in canvas and black cloth, with a no-smoking message and information on the BMSCP clinics that were distributed throughout the Aboriginal communities in 9 locations of the Central West NSW an are covering around 40% of NSW. The initial bag order was 3,000 paid for by the BMSCP project, and a further 6,000 bags (in 2 successive orders) were developed by BMSCP, but paid for through negotiation with a pharmacotherapy manufacturer. Of these promotional bags, 7,000 have already been distributed into the Aboriginal communities totalling 13,500 people (great coverage for the project). Bila Muuji has also been the recipient of 5,000 Aboriginal themed comics on smoking cessation, developed through ITCI, and are in the process of distributing the remainder of these comics to the communities. BMSCP through the one on one training between Smoking Cessation Advisors (AHW in training employed by BMSCP) and clinicians, have produced 4 fully trained Smoking Cessation Specialist Clinicians, and 3 health promotion workers with in-depth knowledge on the “Harmful Effects of Smoking”. Due credit to the BMSCP Team (Floating Clinicians) who have “stuck to the project plan” and delivered the program covering around 4,000 kilometres a week through Kangaroos, Emu‟s, Dust Storms, Floods (not without incident) to effectively deliver a program that they absolutely believed in” “Melissa coming here every week” Q7 - “If money available “Agree but concerned about support for worker in clinical decision making” “We are currently trying to source funds to run a similar Clinic to the Smoking Cessation, however, the expertise of the Clinical Nurse Consultant (Melissa Romeo) who has worked intensively with Drug and Alcohol Clients previously and who has an immense knowledge of addictions will not be included in the Program. The unique experience of having Melissa Romeo facilitate the Smoking Cessation at Thubbo has placed Thubbo AMS at an unfair advantage to the other AMS‟. Melissa has not only facilitated the Smoking Cessation Program at Thubbo but she has also trained one of our own Aboriginal Health Workers to become a Smoking Cessation Clinician.”



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● Q7 – “depend on other program funding.” ● Q8 – “Yes, definitely. Reported for the value of information re low socio economic populations” ● Q4 – “Could have more” Question 9 What do you consider to be the best components of this project? ● “The clinical aspect. Providing free NRT and ongoing support” ● The combination of counselling and clinical/medication support” ● “The fact that we could approach the communities during consultation and guarantee that the

● ● ●

● ● ●

program will run for 2 years, gave us a lot of credibility and relevance at the start of the project. That Aboriginal communities could seek counselling and treatment from people genuinely interested in improving Aboriginal health, from people very experienced in working with Aboriginal people, from people very experienced in smoking cessation, and for the community having a complete understanding of the cessation process. The SCA‟s are an equal part to the success of this project, and are relevant in connecting to community. The project has produced evidence to support the quit rates, through many different statistics and Carbon Monoxide readings and can confidently be quoted, anywhere at anytime without fear of contradiction, and in my opinion is the only evidence based program available, to support reduction rates in smoking for Aboriginal people.” “Weekly sessions” “The capacity building of the AHW. The frequency and reliability of the clinic‟s-excellent service delivery. The support provided by the smoking cessation clinician” “That this project was based on a one on one (face to face) session with clients, which is where we were able to give them information on smoking and its effects with health. It gave the knowledge and support that they needed, because not everyone takes in messages from a television or radio, or get support they need over the phone. Also that it is a cut down to stop smoking program, and NRT products are supplied to clients” “The best Components of this project is that clients who present with complex matters such as: Mental Health issues or Cannabis use are able to be treated for their smoking addictions and also address some of their other ailments they maybe inquiring about.” “Having capacity built into individual services to manage smoking cessation” “The fact that we can provide an intensive clinical based program to clients who are from lower socio economic backgrounds who have the highest smoking rates in western NSW. This population also has the biggest impact on our hospital system. This program has allowed us to address the health needs as well as the social emotional wellbeing of clients in an holistic way. Being able to see the difference in the clients lives when they have quit. Treating other family members when one has quit and we are vouched for as being ok. If a client has relapsed giving them the opportunity to be able to come back on the program with no criticism which then allows them to quit successfully. The changes within the community knowing that they have a service that is designed to meet their needs. Having qualified tobacco treatment specialist who have the knowledge and also empathy to help their clients. Meeting and understanding the disadvantages that this population faces and being a voice to being able to relay that back to Federal Government. Surveying the communities in regards to the effects of the tax increase has had on this population and knowing that it is not making a difference but only increasing more hardship for them. Evidence to show that the government PBS scheme for the Aboriginal population does not work. And that the prescribed amount of NRT on PBS is way below the dose needed to treat highly dependent clients and therefore is setting up clients who want to quit fail. Seeing the evidence that in some homes there is up to 10 other smokers within the house that smoke which therefore is difficult for one person to quit. Evidence to show that the dosage for nrt as prescribed on packaging is way below the dose needed for someone to quit. The benefits of using a smokerlizer to verify the results as well as a tool to motivate the client to quit. Hearing the narrative of the client on the program.



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● ● ● ● ● ●

Using a local person as an SCA is the key to the success. Using local knowledge and cultural understanding. Seeing the growth and the work opportunities for the SCA‟s Support from the local AMS practice managers/CEO‟s That this evidence based clinical model works.” “My staff workers ability to run the clinics” “Their success rate and the interest from the community in gaining assistance in smoking cessation program” “The regular clinic delivery and the supply of medicines (patches, inhalers, microtabs etc.) to the community, at clinic at no cost. The advice and counselling given to the patients in a respectful and dignified manner was much appreciated by the community.” “Seeing staff quit-which reflects on the local community. Geoff‟s amazing ability to educate, not humiliate.” “The availability and consistency and a much needed service provided by skilled and specific staff. The provision of relevant resources and materials to clients.” “The ability of co-ordination of the project to all AMS. The support and backup of our smoking cessation worker.”

Question 10 What do you consider to be the weaker components of this project? ● “Lack of new funding” ● “That we couldn‟t take on more clients particularly initially” ● “The program has a few shortcomings which is to be considered. As I developed the project as

● ●

● ●

● ● ● ● ● ●

best I could from very limited research in Australia and from international programs (mainly Native Americans). The DoHA asked me to reduce my original project proposal to accommodate a funding of $3 million over 2 years, I did this mostly by relieving the project of the TV and Media health promotion, but I kept the delivery and out comes constant with the new budget. I had to cut my employment of AHW as trainee clinicians to 2 days per week (originally set at 5 days per week) to work within the budget, yet still deliver their training and cover their expenses at the respective ACCHS. After funding was received from DoHA I was informed that GST had to be paid which was $300,000.00 I had not catered for, which impacted on the flexibility and aspirations of the project.” “On completion of project there will be no further support for the worker. Disappointing that the project has to come to an end” “The Weaker Component about this Project would have to be that it only runs one day a week. It would be ideal for the Clinic to run more than one day a week as it is so successful. Also other services as well as Thubbo including the two main Hospitals in Dubbo expressed interest in Melissa attending to present an in-service about the Smoking Cessation Clinic to their staff – including their Dr‟s as there was not enough funding or time this was not possible.” “Lack of team meeting and down time for smoking cessation clinicians. Communication with Management of the program.” “More understanding/support from Federal Government funding body that it takes hard work and dedication to provide these results but the outcomes are so worth it. Funding body listen to other agencies and organisation such as AHMRC that have heard our story and support our program To have more funding to provide support for the clinicians on an locum system Mother Nature when flooding occurs and unable to get stock or staff to clinics.” “Limited consultation in issues pertaining to my service and my community” “There has been inconsistency of staff to assist with the follow up of patients” “There needs to be more advertising of the clinic‟s, maybe local radio, and TV with Aboriginal people speaking to Aboriginal people.” “Needs more advertising-Doctors referrals, and word of mouth are not enough.” “Sustainability” “Not enough resources in the clinical area of the project.”



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Question 11 How could the clinics be improved? ● “More promotional items, local people in ads” ● “No suggestions as runs well” ● “ Clinics could be improved by employing SCA‟s on a 5 days a week basis, and providing outreach

● ● ● ● ● ●

● ● ● ● ● ●

clinics to aboriginal Old Age Homes, Hostels, Mental Institutions etc. Clinics will also benefit from public health promotions including. “Mens Pit Stop” world No tobacco Day, sport meetings etc by active participation and referral from AHW‟s.” “More clinic days” “Transport officer” “More clinic days. Ongoing NRT available.” “Clinics are running fantastically I think the only thing that could improve them would be to have them running everyday and train additional staff.” “Better structure supported by the AMS allowing SCAs to be dedicated to the clinic ,not allocated as an afterthought. Plan for when SCA is on leave to follow up clinic” “Concurrent funding!!! Employment of new SCA‟s to work under the trained SCA‟s so that we have more capacity building within each community. Less travel for the current clinicians. Locum available when needed if clinicians sick or unable to attend clinic. Funding body staff to travel to clinics and see clinics in operation. So that they have a better understanding of this program. Employment of an Administration officer to provide clerical and data input for the clinicians.” “I found no issues with my staff member and how the clinics were run” “Regular follow up” “By being available for longer periods per week maybe going from 1 day to 2 days per week.” “I believe Geoff ran his clinic wonderfully and makes a strong connection with the community. His influence make a large impact to our small community.” “More education to all clinicians on impacts and affects of smoking” “By providing resources to the clinical aspects and continuous funding.”

Other Comments ● “It is working” ● It has been one of the few projects where clients have written letters of appreciation” ● “The project has been very successful in delivering everything it set out to do, and the excellent

● ●

● ● ●

● ●

take up rates by the Aboriginal community and the continual waiting list to get onto the program, with evidence based quit numbers, and people on harm reduction exceeding expectations, the need for the BMSCP program to continue, expand and reach across all of Australia is evident.” “Excellent experience and well delivered service” “The Smoking Cessation Project has been an integral part of the Multidisciplinary approach to Health Care Thubbo has undertaken to Close the Gap. As an enormous amount of Chronic illnesses and early Mortality are caused from tobacco use, the Smoking Cessation Program just made sense. Active Prevention and Early Intervention are major factors in Closing the Gap and the Smoking Cessation Program assisted hugely in both of these processes. The end of the Smoking Cessation Program will leave a hole in Thubbo‟s Client Chronic Care” “This is the best way to support smokers trying to quit. We need to differentiate this funding from Early intervention and Prevention, all staff involved in tackling tobacco need to understand the clinical component this program provides” “It has been pleasing to see how many patients are accessing the service” “The Project in my area has been outstanding, in many ways first the clinic‟s, then the presentations to maternal groups (pregnant women), Mums & bubs groups, men‟s groups, and women‟s groups. Then with working with the local council to put up no smoking signage at popular smoking spots, including; outside the magistrates court, outside the council building entrance, and at the public swimming pool, this was the first signage for no-smoking in the towns history.” “I think that shock value has a influence-it works for me. I was also amazed how well Geoff educated-not lectured, which made you want to change with his support and not feel bad about yourself.” “The long term outcome of „change‟ will not occur if the program ceases in October 2012. For any change to happen we should be focussing on a 3-5 year change process. “



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Discussion and Recommendations The project team have reached a consensus that the majority of Aboriginal smokers understand the health implications of continuing smoking and want to give up. However, there are many environmental and social factors that impede that desire. Access to the emotional and technical support provided by this Program is a partial antidote to the impediments. The program has provided a reliable and trustworthy service for the many people who have wanted to quit smoking even and commonly when this has required several attempts to quit. There were many reasons offered for unsuccessful quit attempts but one of the key achievement of the project has been the willingness of clients to return to the Program often with increased confidence and determination. Reasons given for not quitting on first attempt on the Program are described in Table 20. Table 20: Reasons given by clients for leaving the Program. Client quit on program. but resumed at 6 months. Client ceased and re-commenced program on 17.05.2011 Client busy with work and away often client attended 3 sessions, missed 2 and was sick on another. Client ceased program due to stress with marriage. Client had a bad relapse towards end of program as her brother passed away. Had then moved away. Client had anxiety. And was not consistent with patches. Under a lot of stress. Client lives an hour away and realised she could not attend every week as part of requirements. Client has ceased on program due to forgetfulness Client wanted to start program due to illnesses. But moved away after 1st week. Client very forgetful and did not attend all appointments Client was pregnant at first attempt. Has now resumed on program but not consistent. Client not committed to program Client can not take to nrt with other health related problems. To return when feeling better Client has emphysema. But not committed to program. Client ceased program as she has moved back to home town. Client is unable to continue program as she lives out of town and is now finding it difficult to get into town every week or fortnight. Client has ceased program. But SCA has followed up with client and client has quit smoking. Client did not complete program due to work commitments Client failed to attend appointments. Not consistent with patches. Client resumed program. Did not attend all sessions last attempt due to forgetfulness Client quit but resumed smoking. Client not committed to program. No longer on program Client attended 2 sessions. Not committed Client ceased on program due to other medications. Client ceased smoking second week of the program. Client has ceased smoking for 6 weeks. Client first attended clinic 27 weeks pregnant with M/H issues and D&A abuse issues, Client had her child removed by DOCs after delivery. Bila Muuji Smoking Cessation Project


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Client has been unable to attend SC Clinic due to work commitments, she has not quit but has cut down considerably. Client successfully completed the program, but relapsed and has started on the program again this week. Client is having some family issues at present and has told us she wants to resume SC once she returns to town Client moved to Queensland where there was no AMS Client moved town Client was going really well and benefited by the close Case management, however client‟s close family member was diagnosed with aggressive Leukaemia, witch caused her to relapse and with the current circumstances that have been forced onto the family. Client has asked that we resume SC clinic when things settle. Client did not return for her second clinic session when we tried to contact her family said she had moved on to another town after a family dispute and we were unable to obtain any other contact numbers. Client had many problems including alcoholism, depression and smoking we ensured Client received adequate counselling and attended 1 doctors app with her to talk about depression, he put her on an anti depressant and Client successfully completed the program and remains smoke free, although sometimes she still attends clinic to get through her psychological thoughts about smoking. Client was a willing participant in the program but her sister told her she shouldn‟t be participating in the program because NRT will cause her to have a heart attack. We tried to talk it over with her on 2 occasions but we cant convince her to rejoin. Client has relapsed and started smoking again, she is currently suffering deeply from depression and will soon be having a stay at inpatients M/H unit. Client has not returned to clinic as it runs during her work hours she remains a smoker. Client attended 5 SC consults before finding out that she was pregnant. Pregnancy is a major deterrent for client as she has always quit when pregnant. and doesn‟t believe she will resume smoking after birth as she dos not want to undo all of her hard work. Has been on the program for 11 months as he relapsed, Client has now been smoke free for 6+ months Client says he is too stressed to try quitting, discussed withdrawals and cue conditioning. Client passed away a couple of weeks after joining the Program, he died of Emphysema caused heart attack. Client had gaps in program lost her son early in the year. Client still on program Client moved away client did not complete program, peer pressure ceased attending, attempting follow up client ceased program after medical issues and stress Client failed to attend first appt. Ceased program family and work related stress. Client ceased program due to family issues client quit but resumed smoking after 6 months. Client recommencing program 18.07.2011 client left town client ceased program client still on program, recovery from recent stroke, SCA monitoring client, daughter also on program client failed to attend appointments drug and alcohol issues and partner smokes inside. failure to consistently wear patches after advice client left program for medical reasons client left program due to family problems

It was noted that many people are “not as comfortable and compliant with taking medications”. Bila Muuji Smoking Cessation Project


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Recommendations ● Continue the program in Bulla Muuji after an internal review to improve the effectiveness of the Program, including: team meetings and case management; on-going evaluation; integrate client clinical notes from the Program with AMS patient medical records; integration with other services and programs offered in AMSs ● Need identified for easy transfer of patient medical records between AMSs to enable continuity of service. ● Consider duplicating the Program in other Aboriginal communities ● Enable SCAs to provide a frontline service in each AMS. This includes; the selection of staff who are passionate and committed to the role; dedicated clinical time for the Program; on-going training; access to supportive clinical supervision ● Maintain a centralised clinical and administrative coordination, supervision and technical support role ● Recognition of professional qualification and capacity of smoking cessation experts including Medicare item number and Provider number. ● Emphasise inclusion of data management and reporting as integral components of an evidence based Program. ● Continue subsidising NRT products for clients in the Program ● Integrate the clinical program with Healthy for Life community prevention programs.



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Appendix 1: Bila Muuji Smoking Cessation Project Schedule Summary Aim of the Project ● Reduce overall smoking prevalence for Aboriginal people in the Bila Muuji ACCHSs. ● Enhance the ability and effectiveness of Bila Muuji ACCHS staff and others to deliver a population based approach to brief intervention. ● Increase quit rates at all Bila Muuji ACCHSs ● Increase Aboriginal community and individual awareness of the harmful effects of smoking though culturally believable programs. ● Reduce community exposure to environmental smoke through community smoke free areas such as homes, workplaces and recreation areas. ● Facilitate the collection and coordination of project data. Objectives, Deliverables and Performance Indicators. Objective 1: Population based brief intervention for the Aboriginal community in each location

●

●

●

●

Deliverables Provide training to smoking cessation advisors (SCA) to enable them to deliver effective education, screening and brief intervention to support indigenous smokers to quit Provide expert clinical training and back up support to SCAs who deliver smoking cessation program; to increase their capacity to deliver interventions to nicotine Indigenous smokers Engage community members who smoke to tell their stories about how much they smoke, why and the barriers to quitting. Educate community members on the harmful effects of smoking.

● ●

●

●

●

Performance Indicator Number of staff who have undertaken training in smoking cessation practices. Increased numbers of indigenous smokers who have access, entered into and completed the smoking cessation program. Local primary health care services systematically deliver comprehensive, evidence based, accessible and culturally appropriate screening and cessation interventions. Increased knowledge by SCA in practices to assist clients to cease smoking, evaluation and participants is positive Increased awareness of the harmful effects of smoking by community members.

Objective 2: Deliver a smoking cessation program at Bila Muuji ACCHS that will provide consultation, assessment, counselling, nicotine replacement therapy and pharmacotherapy, support and motivation to Aboriginal clients.

● Provide expert clinical training and specialist support to clinicians, GPs, primary health care workers, SCA and medical staff to increase the capacity to oversee the interventions and cessation support delivered by health workers. ● Development of promotional activities to raise the awareness of the effects of smoking ● Suitable trained clinicians to provide training and support to SCA and health workers. ● Provide cost free nicotine replacement therapy and pharmacotherapy


● A culturally appropriate community intervention program to address smoking amongst the indigenous communities is implemented. ● Increased number of community members who have entered smoking cessation program. ● Increased number of community members who have successfully ceased smoking. ● The use of cost-free nicotine replacement therapy and pharmacotherapy, where required as part of community members treatment when entering the smoking cessation program


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Objective 3: Develop smoke free areas such as workplace, home, public and recreational areas

● Actively engage the community to support the establishment of smoke free areas such as house, workplaces and recreational areas.

● Families and communities establishing smoke free house, workplaces and recreational areas. ● All Bila Muuji ACCHS to be smoke free compliant.

Project Outcomes ● ● ● ● ●

Significant reduction in tobacco smoking in the targeted communities. Reduced uptake of tobacco smoking by target group Reduced exposure to passive smoking i.e. in workplaces, homes and recreational areas. Increase in knowledge about the negative health and cultural effects of tobacco smoking Increase intent by community members to quit smoking i.e. quit attempts, reduced tobacco consumption ● Increase in positive attitudes to smoke free living in the community.



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Appendix 2: Survey form of AHS CEOs, Practice Managers, Project Staff The Bila Muuji Smoking Cessation Project (BMSCP) was one of a number of projects funded by the Indigenous Tobacco Control Initiative to promote smoke free messages, inform smokers of the dangers of smoking and assist them to quit smoking. The aim of the BMSCP is to improve the health and well being of Aboriginal people and reduce the prevalence of cigarette smoking in specific communities defined by access to Bila Muuji community controlled health services (ACCHS). The Project is due to finish this month and a final report to be completed by mid July 2012. The opinions and comments of AHS CEOs, Practice Managers and Project staff are an important component of this final report. You th are invited to respond to this survey and return to Geoff du Toit by the 30 June 2012. The following table requires your response by placing a tick () in the cell that best describes your response to each question. Please feel free to add comments about any of your responses in the „Comments‟ section located after the table. Question

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

1.Tobacco control and quit smoking are key strategies to improving the health of Aboriginal people in your community. 2. You and your community were adequately consulted during the planning of this project 3. You have received an appropriate level of communication about the progress of the project over the last 2 years 4. The number and quality of clinics in your health service provided by the Project has been excellent. 5. The education, training and support for local Smoking Cessation Advisors (SCAs) has been excellent. 6. Acceptance and support for the Project clinics amongst your staff and in your community has been excellent. 7. You intend to continue the Smoking Cessation clinics after the project funding ceases in July 2012. 8. The project collected data from clinic participants on issues such as: residence in smoke free homes; use of smoke free cars; support for plain packaging of cigarettes; and, likely impact on tobacco use of cigarette price increases. Should this data be analysed and reported by the project?

Comments



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9. What do you consider to be the best components of this project?

10. What do you consider to be the weaker components of this project?

11. How could the clinics be improved?

12. Any other comments about the Project?

Thanks for completing this survey. Your responses and comments will be included in the final Project report. Your Name:


Your work title:


Date

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Appendix 3: Thubbo AMS Testimonials of Quit Smoking Clients NAME: ANNETTE MACKAY

NAME: BRUCE WILSON

STARTED SMOKING: 1972

STARTED SMOKING: 1989

QUIT: March 2011

“I came to Thubbo’s Smoking Clinic on the 21st March 2011 and haven’t smoked since. I definitely don’t miss the coughing...No more smokes no more cough ”

NAME: CHARLEEN MCALLISTER STARTED SMOKING: 1996 QUIT: January 2012

”I got all the support I needed from Thubbo”

NAME: GLENN LAWRY STARTED SMOKING: 1987 QUIT: April 2012

“Its a great Program and I am so greatful because it works”

NAME : KRISTIE NOLAN STARTED SMOKING: 2000

QUIT: October 2011

“Thubbo’s Quit Program is life changing not only for me but also for my whole family”

NAME: JASON NOLAN STARTED SMOKING:1994 QUIT: February 2012

“The Program really works and it can really help more of our people stop smoking”

NAME: JEFF PEARSON STARTED SMOKING: 1963 QUIT: February 2012

“ After 40 plus Years of smoking the AMS helped me quit in 2 weeks”

NAMES: REBECCA HUTCHINSON & MATHEW WRIGHT • STARTED SMOKING: (Bec – 1990) (Mat – 2008) •QUIT: (Bec & Mat – December 2011)

QUIT: October 2011

“ I love being able to call myself a Non – Smoker, I love that my kids can say their mum is a Non – Smoker”


“ The Program has changed our lives, it made it so much easier that we could do it together Thubbo was fantastic!!”


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NAME: JOHN DERRICK STARTED SMOKING: 1977

NAME: CHRISTINE MINCHELL STARTED SMOKING: 1995

QUIT: October 2010 QUIT: August 2011

“Thanks to Thubbo, I have more energy and I am much more active”

“I have more time, I have more money, I have more control over my life”

NAME: Beverley Ryan

NAME: KEVIN SHIPP STARTED SMOKING: 1985

STARTED SMOKING: 1981 QUIT: January 2011

“I had a Heart attack because of the smokes a year ago and I got a second chance so I thought I’m not going to waist it. The Program helped me quit in February 2011”

NAME: Patricia Powell STARTED SMOKING: 1960 QUIT: 4th November 2010

“ I had a blockage in my heart, I was told if I didn’t quit I would have a stroke or Heart attack. Thubbos Smoking Cessation Program helped me quit. Thanks to Melissa I have money, energy and most important my life”


QUIT: June 2011

“I was ALWAYs broke and now I ALWAYS have money and a house full of new furniture, thanks to the Smoking Cessation Program, I feel great and I have money”

NAME: Lola Roberts STARTED SMOKING: 1965 QUIT: December 2010

“ I was struggling on Champix when I started the Program and the difference was that on the Program I understood how NRT and Champix worked and we tailored it to suit me and then it was simple”


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Appendix 4: Brewarrina Cowboy kicks the habit to wrangle bride at last Brewarrina News 7th June 2012.


May 2012 Interim Evaluation Report

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