“Stop Smoking in its Tracks”:An incentives- based smoking cessation program for Australian Aboriginal women provided by antenatal services – a pilot study

Megan Passey, Rob Sanson-Fisher and Janelle StirlingUK National Smoking Cessation Conference

London, June 2014

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Collaborative projectUCRH, University of Sydney: Megan Passey, Jenny Gale, Janelle

Stirling, Cathy Malla Aboriginal Maternal & Infant Health Strategy (AMIHS) program:

Catherine Leatherday, Brenda Holt, Cathy Powell, Sue Rogers, Paula Craig

University of Newcastle: Rob Sanson-FisherCommunity Reference Group: Aunty Bertha Kapeen, Delta Kay,

Virginia Paden, Laurel Rogers, Careena Roberts, Janina Roberts, Dana Lavelle, Joyce Roberts, Akarna King, Edith King

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Prevalence of smokingAustralian adult population in 2008:

Aboriginal and Torres Strait Islander Australians – 47.0%Non-Indigenous Australians – 17.5%

Pregnant women in Australia in 2010:Aboriginal and Torres Strait Islander women – 50.9%Non-Indigenous women – 14.4%

Among Aboriginal and Torres Strait Islander women:Highest in outer regional areas, lowest in citiesDeclines slightly with age

(Scollo and Winstanley 2012)Laws and Sullivan, 2009

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Request to help develop quitting program Few published articles addressing smoking or cessation by

pregnant Aboriginal women Much of the Indigenous research available was done in

remote settingsGeneral smoking cessation literature gives little guidance

on Indigenous specific issuesLittle relevant grey literature; lots of anecdoteOnly one properly controlled trial of a smoking cessation

intervention with pregnant Indigenous Australian women – not effective (Eades et al, 2012)

Formative research to help design the quitting program

1. Qualitative study on North Coast Interviews with women Focus groups with women and service providers

2. Survey of antenatal staff caring for Aboriginal women

3. Survey of pregnant Aboriginal women

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Social drivers of smokingSmoking ‘normal’ in Aboriginal

communities When you don’t smoke you stand out a bit, you feel a

bit odd…. Cause everyone around you smokes. Everyone that I know smokes. There is not one person that I know in [town] who doesn’t smoke. So like, it is a bit hard. 24 year old smoker

Cultural issues and smoking Relationships, obligations and need to

belong identified as barrier to quittingSharing cigarette and having a yarn

contribute to social cohesion and sense of belonging

(Passey et al, 2011)

More barriers to quitting

High levels of stress and previous trauma

Partner and other household members smoking

Low self-efficacy for somePoor knowledge of risk and lack of salience

of risk informationAddiction and habitPleasure of smoking

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Tobacco, cannabis and alcohol

Survey with pregnant Aboriginal women in NSW

and NT (n=257):

46% reported smoking tobacco

15% reported smoking cannabis

21% reported drinking alcohol

Smokers more likely to also: Drink alcohol (OR=4.3; 95%CI: 2.12, 9.13)

Smoke cannabis (OR=10.2; 95%CI: 3.73, 34.52)

Assess & support all

women

Contingency based

rewards

Free NRT Resources:Brochures,

magnets etc

Post-partum support

Social support groups

Other drugs (alcohol, cannabis

referrals)

Household members

Assist AMIHS

team to quit

Build on existing services - AMIHS:• Regular antenatal visits• Good relationships• Ongoing support

• Widely accepted in community & homes

• Cultural & community knowledge• Reinforcing each others messages

Empowerment approachG o a l s , p e r s o n a l r e w a r d s , b e l i e f i n a b i l i t y t o q u i t

Schedule for visits and rewards

Starts at first antenatal visitTwice weekly for 3 weeksWeekly for next 4 weeksFortnightly till the birthWeekly for 6 weeks post-partumFortnightly till 6 months postpartumValue starts at $10, increasing by $2 each visit if

confirmed non-smoking

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Pilot testing Stop Smoking in its Tracks2 AMIHS sites trained and provided with resources

and supportAssessed:

Feasibility – provider views, implementation indicators, notes from meetings

Acceptability – to women and providers – interviews, participation rates, notes

Impact – on smoking behaviour, other impacts – record keeping by providers, notes

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Participation and completionParticipation rate Completion rate

6016

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22 out of 38 eligible (58%) consented

not eligiblerefusedconsented

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19 out of 22 (86%) completed

36 week datawithdrew

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Quit rates – (confirmed by expired CO)

quit attempt successful quit quit at 36 weeks0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

84%79%

42%

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Rewards issuedAmount per woman ranged from $56 to $820Median amount issued was $294

Majority used at electrical appliances stores, then pharmacies

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FeasibilityTeam capacity

Frequency of visits

Running groups

Distance and transport

NRT expiry dates

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Women’s views

Loved the frequency of support, especially when trying to quit or maintain quit status

Rewards very motivating AMIHS always mentioning smoking helped women

realise how important it wasOngoing support helping women with strategies was

valued “it seems like they really care”

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AMIHS team views

Good to have something to offer women to help them quit – much more powerful than usual care

Combination of rewards with the other support was really effective

Women who quit were very proud of their successThought that most women really valued the rewards

and the frequency of the support

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Views on RewardsConsidered powerful motivator in one site, but not as

powerful with some women in other siteHelped women maintain their motivation and

prevent relapse

“I think the biggest word is proud. They were just so proud of themselves that they got enough vouchers to get a hair straightener or a – one got a fridge”

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Conclusions - the program was:Acceptable to both women and the providersFeasible to implement but needs adequate staffing levels and

capacity Impact – high rates of quitting behaviour with confirmed

quitting in late pregnancy similar to other programs including incentives

Modifications – consider reducing duration of frequent visits and/or dropping the groups

Next phase – larger trial to assess impact in pregnancy & postpartum; adverse effects; feasibility in different settings

Thank you!Acknowledgement of FundingStudies funded by the Australian Department of

Health and Ageing under the Indigenous Tobacco Control Initiative

Currently supported by fellowships from the NHMRC and the NSW Cancer Institute

Contact: megan.passey@ucrh.edu.au

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