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�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia
Lessons for Aboriginal tobacco control in
remote communities: an evaluation of the
Northern Territory ‘Tobacco Project’
David Thomas, Vanessa Johnston and Joseph FitzMenzies School of Health Research and Institute of Advanced Studies, Charles Darwin University, Northern Territory
Tobacco use is the single most
important risk factor for excess
mortality and morbidity among
Indigenous people, responsible for one-fifth
of Indigenous deaths in 2003.1 Indigenous
smoking rates are highest in the Northern
Territory (NT), where 54% of adults are daily
smokers.2 In some remote NT communities,
the prevalence of smoking is even higher.3
A comprehensive approach, with many
different elements of tobacco control, is
promoted as the most likely to succeed.4
A literature review has inferred which
tobacco control activities are most likely
to be effective in Aboriginal communities,
with evidence usually coming from
research in other populations given the
paucity of Aboriginal tobacco control
research.5 Nevertheless, evaluations of multi-
component tobacco control interventions
in Indigenous communities have identified
only small impacts on smoking. A study
of three intervention and three matched
control NT communities only found a
reduction in tobacco consumption in one
intervention community compared to its
matched control.6 In eight north Queensland
Indigenous communities, smoking fell from
61% (of 698) to 57% (of 596).7 Similarly,
a Cochrane systematic review of multi-
component community interventions found
only minimal differences in smoking in
intervention and control communities,
including the two most rigorous studies.8
Nevertheless, the Australian Government has
announced more than $10 million for such
Submitted: December 2008 Revision requested: April 2009 Accepted: August 2009Correspondence to: Dr David Thomas, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0810; and Institute of Advanced Studies, Charles Darwin University, NT. Fax: (08) 8927 5187; e-mail: [email protected]
Abstract
Objective: To evaluate a Northern Territory
(NT) government-led pilot ‘Tobacco Project’
in six remote communities.
Methods: Monthly surveys of staff,
semi-structured interviews with staff and
community members, observation of the
delivery of tobacco control interventions,
review of Project documents, and
monitoring of tobacco consumption using
sales (or wholesale orders) of tobacco.
Results: There was a substantive amount
of tobacco control activity delivered in
three of the Project communities. In two
of these locations, the majority of work
was primarily driven and undertaken
by resident staff. Overall, most of the
Project’s efforts related to community
education and awareness-raising. There
was variable impact of the Project on
tobacco consumption across the six
communities. More tobacco control activity
was consistently associated with a greater
reduction in tobacco consumption. An
important predictor of local activity was the
presence of strong community drivers. A
significant obstacle to the Project was the
lack of new resources.
Conclusions: Despite the minimal impact
of this Project on tobacco consumption
overall, there was a consistent association
between on-the-ground tobacco control
activity and reductions in tobacco
consumption.
Implications: New initiatives will not only
need to provide new funding, but identify
and then support local staff, who are
central to improving local tobacco control
activity and so reducing smoking and
smoking-related illnesses and deaths.
Key words: smoking, tobacco, Indigenous,
evaluation, remote.
Aust NZ J Public Health. 2010; 34:45-9
doi: 10.1111/j.1753-6405.2010.00472.x
multi-component interventions in Indigenous
communities.9 This paper evaluates a recent
multi-component tobacco control project in
six Indigenous communities, and will further
add to our understanding of the impact of
such projects, and the key enablers and
obstacles of their impact on smoking, in the
context of this new policy initiative.
The Tobacco Project The Northern Territory Department of
Health and Families (NTDHF) (formerly
the Northern Territory Department of
Health and Community Services) ran
a pilot ‘Tobacco Project’ in six remote
Aboriginal communities from January 2007
to June 2008. The Project was supported by
the National Heart Foundation and local
councils, health clinics and health boards in
the six communities.
The communities were asked to prioritise
and plan tobacco control activities from a
list of tobacco control interventions, for
which the Project could provide support.
Each community had a different range and
intensity of tobacco control activities; there
was not a single Project package that could
neatly be evaluated in each site. Importantly,
no new NT government resources were put
towards the Tobacco Project; the Project
could only co-ordinate and redirect the
existing resources of the NTDHF Programs
in these communities.10 While the Project
was associated with considerable planning
and co-ordination activity in Darwin, the
lack of specific additional Project resources
Article Indigenous issues
4� AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �010 vol. 34 no. 1© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia
and funds constrained the intensity of tobacco control activity in
the communities.
Menzies School of Health Research was invited to evaluate the
project. While the aim was to evaluate the impact of the Tobacco
Project, this could not always be neatly separated from activities
that would have occurred without the Project.
Context – the six communitiesFive of the communities (A, B, C, D and E) were located in
the Top End of the NT and the sixth (F) was in central Australia.
Community F joined the Project significantly later that the other
five, in late 2007.
The Project communities ranged in population from 130 to
more than 2,000. Community A is a cluster of four main sites,
three of which have mostly Aboriginal residents. Community E,
the smallest of the Project communities had no store. By contrast,
in Community B there were five different tobacco retail outlets
operated by different local organisations and an established health
centre and Aboriginal-controlled Health Board.
In all but two communities (A and C), there had been little
concentrated effort on tobacco control in recent years.
MethodsThe evaluation used a mix of data:
• Monthly staff questionnaires of tobacco control activities
delivered.
• Semi-structured interviews with 25 Indigenous adults in two
communities.
• Semi-structured interviews with 19 health and welfare staff.
• Observation of and participation in monthly Steering Group
meetings and review of meeting documents.
• Observation of tobacco control activities in three
communities.
• Sales (or wholesale orders) of tobacco at community stores
and takeaways (except in Community E, where there was no
community store).
Sampling of community members for interviews took place
at three sites (although most (n=21) occurred in one large Top
End community). Health and welfare staff interviews included
government and non-government workers living in, or who visited
regularly, all of the Project communities.
We described the range of tobacco activities delivered; it
was not appropriate to present statistical data on the intensity
of activities across the communities because the data was of
insufficient quality.
Tobacco sales or wholesale invoices from each site were
converted into cigarette (stick) equivalents, with 0.8g of loose
tobacco equivalent to one cigarette, consistent with national
reports.11 If sales data were not available, we described monthly
tobacco consumption using three-month rolling averages of
wholesale invoices. We have shown elsewhere that the average
of three months’ wholesale invoices provides a close estimate of
monthly tobacco sales.12 We compared the total sales (or wholesale
invoices) of tobacco products in the 2006/07 and 2007/08 financial
years, and in the last six months of 2006 and 2007.
ResultsOf the 19 staff interviews, 15 were town or bush-based NTDHF
staff (nine women and four Indigenous staff were included).
Twenty-three health staff consented to providing feedback on
their activities via a monthly questionnaire, but nearly half (11/23)
resigned, took extended leave or moved to different positions
during the Project. The response rate to the monthly questionnaire
was variable and was particularly poor for the last six months
of the Project (monthly response rates between 20 and 40% of
consenting staff, January-June 2008).
1. Tobacco interventions delivered by the Tobacco Project
The range of tobacco interventions delivered by the Tobacco
Project
Across all six communities, most of the Project’s tobacco control
efforts related to community education and awareness-raising
(Table 1). This included group information sessions, the use of
specific health promotion media (e.g. posters, pamphlets, visual
displays), tobacco education as part of general health promotion
and the use of traditional storytelling to reinforce anti-tobacco
messages. These interventions were directed at a range of target
groups: adults, pregnant women and children.
During the Project, a media campaign was launched that targeted
Indigenous youth, the ‘I’m Smarter than Smoking’ campaign.
NTDHF evaluated this campaign by using a survey of 820 NT
Table 1: Tobacco control activities.
Community A Community B Community C Community D Community E Community F
Category of tobacco control activity Increase exposure to ++ +++ + + ++ +++ tobacco control messages
Increase provision of smoking ++ ++ + + + ++ cessation interventions
Increase smokefree areas + ++ + 0 + ++Reduce store display of + + + 0 N/A 0 tobacco products
Notes: +++ = significant activity; ++ = some activity; + = little activity; 0 = no reported activity; N/A = not applicable
Thomas, Johnston and Fitz Article
�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia
Indigenous issues Evaluation of tobacco project in the Northern Territory
students to assess their attitudes towards this campaign compared
with other advertisements. There was no assessment of the impact
of the campaign on smoking initiation or cessation. There were no
changes to NT tobacco control legislation during the Project, and
taxation on cigarettes only increased in line with CPI.13
Where did most activity occur?
There was a substantive amount of tobacco control activity
delivered in three of the Project communities (A, B, F). In two of
these communities (A and B), the majority of work was primarily
driven and undertaken by resident staff and for the most part,
happened alongside (rather than because of) the NTDHF Tobacco
Project.
In Community B, the local health board ran a tobacco control
program from July-December 2007 (the ‘Smokebusters’ Project),
funded independently of the NTDHF Tobacco Project, which
employed two locally based staff members (one full-time Project
Coordinator and one half-time Tobacco Support Worker). This
project was associated with the most intense tobacco control
activity of all participating communities, delivering a diverse
number of tobacco interventions that included: providing free
NRT and counselling to community members; running smoking
cessation courses and one-on-one sessions with clients; providing
education in the school; running a community awareness campaign
to reduce secondhand smoke exposure of children; working with
different community organisations to comply with tobacco control
legislation; working with the clinic to promote brief intervention;
and applying for funds to sustain local tobacco control activity.
In Community A, a high level of activity (including NRT
education, subsidisation and distribution, strong support for
smokefree public areas and work sites, and ongoing education)
was also reliant on resident health staff who were committed to
Aboriginal tobacco control and had longstanding relationships
with community members. Successes here included the cessation
of sales of cigarettes at a supermarket (after lobbying from the local
doctor), and the heavy promotion of ‘No Smoking’ areas on clinic
grounds and at the airport. In this context, the NTDHF Project was
able to support and foster activity that was already happening in the
community, even though the Project did not initiate a significant
amount of additional tobacco control work.
Community F was a slightly different story again. In this
community, interviews indicated that the Tobacco Project acted as
a significant driver to scale up NTDHF Alcohol and Other Drugs
program work on Aboriginal tobacco control. Activity included
the provision of group information and education sessions, heavy
promotion of smokefree areas at the council, clinic and youth
services, and efforts to engage the clinic in increasing the use of
smoking cessation pharmacotherapies and brief interventions.
This local activity was supported or driven by visits from NTDHF
staff from Alice Springs, with strong involvement from several
local organisations: the council, the local youth program and the
store.
In the three other Project communities (C, D and E), there was
comparatively little reported activity. For example, in Community
D, there were only two visits by NTDHF staff during the course
of the Project; this was partly attributed to difficulties engaging
with the clinic staff at this site.
2. Tobacco consumption Data from six Project sites (two sites in the community A cluster,
and all other communities excluding community E, where there
was no store), demonstrated a 1.2% reduction in daily tobacco
consumption in 2007/08 compared with 2006/07. And there was
a 5% reduction in tobacco consumption in the second half of
2007 (when most project activity occurred) compared with the
same time in 2006.
Tobacco consumption decreased in both the 12-month and six-
month comparison in only three locations (Table 2). The greatest
relative reduction in tobacco consumption occurred in Community
F. However, because community F is a small community, this was
only associated with a very modest absolute reduction of less than
a packet of cigarettes every day.
Community B had the greatest absolute reduction in tobacco
consumption in each comparison. In 2007/08, 182,077 less
cigarettes were sold than in 2006/07. Indeed, if the results from
community B are excluded, there was an overall 3.5% increase
(rather than a decrease) in tobacco consumption in the remaining
four locations (2007/08 vs 2006/07), and only a small 0.6%
reduction in the six-month comparison.
In community B, the sharpest decline in consumption coincided
with the start of increased local tobacco control activity, and the
employment of a public health nurse and tobacco community
worker in mid-2007, followed by a period of consistently lower
consumption. Tobacco consumption returned to previously higher
levels of consumption soon after the local activity and Project
collapsed at the end of 2007. There was no such neat temporal
Table 2: Comparisons of tobacco consumption.
Average number of % change in Average number of % change in cigarettes/day cigarettes/day cigarettes/day cigarettes/day
2006/07 2007/08 July-Dec 2006 July-Dec 2007
Community A
Site 1 1,838 1,865 -1.4% 1,976 1,819 -7.9%
Site 2 1,696 1,984 +17.0% 1,876 1,954 +4.1%
Community B 12,661 12,129 -4.2% 11,840 10,849 -8.4%
Community C 2,931 2,786 -4.9% 2,952 3,040 +3.0%
Community D 1,603 1,733 +8.1% 1,790 1,766 -1.4%Community F 374 352 -5.7% 382 342 -10.6%
4� AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �010 vol. 34 no. 1© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia
correlation between reductions in tobacco consumption and
Project activity in other sites.
3. Perceptions about enablers and obstacles to tobacco control
Community readiness for tobacco control
The places where most activity took place (communities A,
B and F) were where stakeholders across the community (e.g.
council, clinic, school) were stated by health staff to be ‘ready’
to prioritise tobacco control. They had identified tobacco control
as a priority, developed local strategies and had dedicated staff
available to deliver services.
‘Community readiness’ was supported by strong local drivers
of tobacco control, who, particularly in Community A, had been
working hard on the issue for years. These stakeholders (usually
clinic or council staff) had established trusting relationships with
the communities in which they lived and could act as a conduit
for further activity delivered through the Project. We observed
that key to the success of these local drivers was that they were
resident in communities and had dedicated duties to tobacco
control (either part or full time). Developing local Aboriginal
capacity was also reported as important in the success of local
efforts in the long term.
Lack of resources Overwhelmingly, health staff reported that a lack of resources
undermined the success of the Tobacco Project and tobacco control
more generally. For the Project, lack of new resources impacted
on the type of tobacco interventions that the Project delivered and
the time spent by staff delivering these. The perception of senior
Departmental staff was that they were still ‘fiddling around at the
edges’ of tobacco control. Budgetary constraints also affected
time staff spent on the Project, while balancing other demands
(this was reported at all levels of staff involvement); the AOD
Community Support Officers who conducted much of the field
visits reported feeling particularly stretched. It also effected travel
and time spent in communities, with the centralised rapid fly-in,
fly-out model perceived as increasingly ineffective in connecting
with community people.
The interviews also identified examples of both successful
collaboration and poor collaboration and conflict between Project
partners, and generic problems encountered in working with these
communities (e.g. seasonal access), in addition to the particular
disruption of the NT Emergency Response. These data are not
elaborated on here (but are available from study authors).
The Aboriginal community informants provided little useful
data on the processes used for this project, beyond being generally
supportive of the community-driven project in community
B, where most interviews were conducted. These informants
however, provided useful data on why remote Aboriginal adults
smoke,14 as well as general perceptions of different tobacco control
interventions.
DiscussionData limitations
The low and variable staff response rate to monthly questionnaires
means that some tobacco control activities may not have been
identified by the evaluation. However, interviews and informal
discussions with health and community staff, as well as regular
attendance at Project Steering Group meetings, provided the
evaluation team with other sources of information about what was
delivered in each of the Project communities, reducing the final
amount of missing data.
Similarly there were limitations of the tobacco consumption
results: the most significant is that there was no fixed denominator
for these consumption results. The potential impact of population
changes means that particular caution should be exercised in
the interpretation of the results, particularly from community F,
where the departure of just one or two pack-a-day smokers from
this location could explain the apparent decline in consumption
in that community. However, local informants in community
B had noticed no significant population change to account for
the dramatic reduction in tobacco consumption associated with
increased tobacco control activity in the last six months of
2007.
Tobacco consumption data from community A need to be
interpreted with caution, as we were not able to report on data
from two of four sites in the cluster. And residents of community
F and Site 1 community A are close to tobacco retail outlets where
we did not access store data because they also service many non-
Aboriginal clients. Nevertheless, store-based indirect measures
of consumption are the preferred measure of consumption in this
setting. In contrast, self-reported numbers of cigarettes smoked
in surveys in remote Aboriginal communities are only weakly
correlated with cotinine levels,15 and estimates of cigarettes
smoked per smoker have demonstrated to be both higher6,16 and
lower17 in surveys compared to store-based estimates. At the
national level, estimates of consumption based on self-report
under-estimate consumption by 26% compared to estimates
based on tax receipts (which are analogous to our store-based
estimates).18 Finally, the study did not include control communities
unlike the two previous studies.6,7 Delays in collecting tobacco
consumption data from other sites meant that there was insufficient
data to make meaningful comparisons.
In spite of these limitations, some clear messages emerge from
the results.
Lessons from the Tobacco ProjectMore tobacco control activity was associated with a greater
reduction in tobacco consumption. While we were not able to
neatly quantify the intensity of tobacco control, we could compare
both places and periods with clearly different intensities of tobacco
control activity. Community B and F, where significant tobacco
control activity occurred, were also the locations with most
consistent reductions in tobacco consumption. Additionally, there
was a greater (5%) reduction in combined tobacco consumption
Thomas, Johnston and Fitz Article
�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia
when we just looked at the last six months of 2007, the period of
greatest reported tobacco control activity, than when the whole
12 months of 2007/08 was examined (1.2%).
The three communities (A, B, F) that saw most activity over
the life of the project were places most ‘ready’ to tackle the issue,
that is, these local communities had prioritised tobacco control,
key stakeholders were on board and resources and staff time were
mobilised. In two of these communities (A and B), health staff and
management had made tobacco control a clear priority and had
allocated additional resources for tobacco control; in community
B, led by the local Aboriginal community controlled health board.
The north Queensland study had similarly suggested that lack of
local ownership of their project had limited its impact.7 In contrast,
the Cochrane review found no relationship between community
involvement and the impact on smoking outcomes.8
The lack of dedicated new resources for the Project was a major
impediment to increasing tobacco control activities. Other low
intensity multi-component community tobacco control projects
in remote Indigenous communities had similarly modest overall
impacts.6,7 In this context, the apparent impact on consumption,
especially in Community B with its significant additional
resourcing is encouraging. Similar levels of additional resourcing
in other communities could lead to significant reductions in
Aboriginal smoking in the NT. The need for adequate new
dedicated funds is supported by American research that showed
that increases in State tobacco control program expenditures
were independently associated with overall reductions in adult
smoking prevalence.19 The planned new multi-component tobacco
control initiatives will not only need to provide new funding, but
identify and then support local staff, who we found were central to
improving local tobacco control activity and so reducing smoking
and smoking-related illnesses and deaths.
AcknowledgementsThis research was supported by a grant from the Cooperative
Research Centre for Aboriginal Health (No. CD 216) and a
NHMRC GP Clinical Research Grant (490300). The NT DHF
contributed additional funds to cover the six-month extension
of the evaluation. David Thomas was supported by a NHMRC
Population Health Capacity Development Grant (#256235).
The evaluation team would like to thank all the participating
Aboriginal communities, community residents and staff, NT
DHF staff, participating community organisations, and stores
and wholesalers.
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Indigenous issues Evaluation of tobacco project in the Northern Territory