Dr Ashleigh Guillaumier

Introduction and Aims: Electronic cigarettes (e-cigarettes) are becoming popular and may be a potential harm reduction and quit smoking aid for people who use other drugs. Data on e-cigarette use and perceptions among people who use drugs is limited. The current study examines tobacco smoking status, use and attitudes towards e-cigarettes among people in drug and alcohol treatment. Design and Methods: Data were collected through a standardised Patient Experience Tracking System device installed in the waiting room of six drug and alcohol clinical service programs located within one area health service in New South Wales, Australia during April to June 2017. Participants were clients of participating services aged 18 years and older. Results: Five hundred and eleven participants completed the survey, 85% were current smokers, 9% were ex-smokers and 6% were non-smokers. Over half of all participants (53%) had tried e-cigarettes in their lifetime, 26% reported current use and 77% of those were using them with nicotine. Just less than half of all participants believed that e-cigarettes were helpful for quitting or cutting down smoking tobacco cigarettes (48%). More than half of all respondents (59%) believed that tobacco cigarettes were more harmful than e-cigarettes (59%) and believed that e-cigarettes were an acceptable quit smoking aid for patients of drug and alcohol services (64%). Discussion and Conclusions: Most participants were current tobacco smokers and had tried an e-cigarette though a minority were currently using e-cigarettes. Participant attitudes were favourable towards the use of e-cigarettes as quit smoking aids.

Background: Tobacco smoking is highest among population groups which are the most socially disadvantaged. Internet-based smoking cessation programs have been found to be effective, though rates of internet access are not well known in these groups. This study describes the rates of internet use and types of technology used to access the internet by a population of socially disadvantaged smokers. The study also examined relationships between sociodemographic and smoking behaviours with amount of internet use and type of device used. Methods: A cross-sectional survey of 369 clients (response rate 77%) from two non-government community service organisations in metropolitan New South Wales, Australia was conducted using touchscreen computers. Descriptive statistics and logistic regressions were used to examine results. Results: Eligible participants ranged from 19 to 88 years old current tobacco users. Over half (58%) of the participants reported weekly or more frequent use of the internet with less than a third (28%) not having any access. The odds of using the internet at least weekly decreased with age and as heaviness of smoking increased (OR = 0.94, p < 0.001; OR = 0.81, p = 0.022, respectively). Odds of internet use were higher as income increased (OR = 2.74, p < 0.001 for individuals earning $201-$400 per week; OR = 2.83, p = 0.006 for individuals earning > $400 per week). Device use differed for age and income. Conclusions: Internet-based interventions appear to reach the majority of socially disadvantaged populations. It is expected that this reach will continue to grow, making internet-based interventions a potential platform for providing care to low socioeconomic individuals who smoke, however inequalities may be exacerbated for those individual without internet access. Implications: Internet use among socially disadvantaged tobacco users is moderate (58%). An internet-based smoking cessation intervention for socially disadvantaged tobacco users may be an effective intervention however, older, heavier tobacco users may not benefit as easily due to limited internet access and therefore acknowledging these limitations when developing an intervention can help to acknowledge limitation of intervention reach.

Background Stroke events often result in long-term negative health outcomes. People who experience a first stroke event are 30%-40% more likely to experience a second stroke event within 5 years. An online secondary prevention programme for stroke survivors may help stroke survivors improve their health risk behaviours and lower their risk of a second stroke. Objectives This paper describes the development and early iteration testing of the usability and acceptability of an online secondary prevention programme for stroke survivors (Prevent 2nd Stroke, P2S). P2S aims to address six modifiable health risk behaviours of stroke: blood pressure, physical activity, nutrition, depression and anxiety, smoking, and alcohol consumption. Methods P2S was developed as an eight-module online secondary prevention programme for stroke survivors. Modelled on the DoTTI (Design and development, Testing early iterations, Testing for effectiveness, Integration and implementation) framework for the development of online programmes, the following stages were followed during programme development: (1) content development and design; and (2) testing early iteration. The programme was pilot-tested with 15 stroke survivors who assessed P2S on usability and acceptability. Results In stage 1, experts provided input for the content development of P2S. In stage 2, 15 stroke survivors were recruited for usability testing of P2S. They reported high ratings of usability and acceptability of P2S. P2S was generally regarded as easy to use' and relevant to stroke survivors'. Participants also largely agreed that it was appropriate to offer lifestyle advice to stroke survivors through the internet. Conclusions The study found that an online secondary prevention programme was acceptable and easily usable by stroke survivors. The next step is to conduct a randomised controlled trial to assess the effectiveness of the programme regarding behaviour change and determine the cost-effectiveness of the intervention.

Background and Aims: Organizational change interventions involve systems and cultural change within health-care services to make smoking cessation care delivery part of usual treatment. Six strategies for organizational change have been proposed. This study examined the evidence for organizational change interventions in the alcohol and other drug (AOD) setting on: (a) smoking cessation care; and (b) smoking cessation and cessation-related outcomes. Methods: A systematic review with narrative synthesis was conducted. MEDLINE, PsycINFO, CINAHL, EMBASE and Scopus were searched using keywords and MeSH terms from database inception to 1 June 2018. Interventions were assessed against the six organizational change strategies. Results: Of the 5155 papers identified, 14 publications from seven unique studies were included. Most studies employed four or fewer organizational change strategies. The majority (n¿=¿11) were rated weak to moderate in methodological quality. Nine published papers, four unique studies, examined staff reported provision of smoking cessation care; eight reported an increase, one found no change. Three papers, two unique studies, examined client receipt of care; all found significant increases. Three papers, two unique studies, assessed staff smoking prevalence from pre- to post-intervention. Only one study reported a significant reduction in staff smoking prevalence (35.2 versus 21.8%, P¿=¿0.005). Nine papers, six unique studies, assessed client smoking cessation and smoking-related outcomes. Seven papers reported on client smoking prevalence; two found a significant decrease and five found no change to smoking. Four papers reported on number of cigarettes per day, three found a significant decrease and one found no change. Two papers reported on smoking cessation finding a 10% and a 25% seven-day point prevalence abstinence post-discharge from the AOD service. Conclusions: Organizational change interventions within health-care services to make smoking cessation care delivery part of usual treatment offer promise for increasing smoking cessation care and reducing smoking prevalence.

Background: Among people who inject drugs (PWIDs) the prevalence of tobacco smoking exceeds 80%; making smoking cessation intervention a priority for this population. This study aims to examine staff and client perspectives from a supervised injecting facility regarding: i) whether an organizational change intervention increased rates of smoking cessation care delivery (pre- to post-intervention); and ii) acceptability of the intervention. Methods: A pre-and-post intervention pilot study in a supervised injecting facility was conducted in Sydney, Australia between July 2014¿December 2015. The intervention employed an organizational change approach and included six components. Cross-sectional samples of staff (pre n = 27, post n = 22) and clients (pre n = 202, post n = 202) completed online surveys pre and post intervention. Results: From pre to post-intervention staff reported smoking cessation practices significantly increased for the provision of verbal advice (30% to 82%; p < 0.001), offer of free or subsidized nicotine replacement therapy (30% to 91%; p < 0.001), referral to a general practitioner (19% to 64%; p = 0.001), and follow-up to check on quit smoking progress (18.5% to 64%; p = 0.001). Significantly more clients reported receiving all smoking cessation strategies post-intervention. Over 85% of staff agreed that it was acceptable to address client smoking as part of usual care and 95% of clients agreed that it was acceptable to be asked by staff about their tobacco smoking. Conclusions: Increasing the provision of smoking cessation care using an organizational change approach is both feasible for staff and acceptable to staff and clients of supervised injecting facilities.

Introduction Clinical practice guidelines recommend alcohol and other drug (AOD) services assess client's smoking status and offer smoking cessation care (SCC) to all smokers. The aim of this study was to examine Australian AOD program staff report of recommended SCC practices: assessment and recording of smoking status; and the provision of 9 types of SCC. The study also assessed how the decision to provide SCC is made and the AOD program service and AOD staff characteristics associated with the provision of SCC. Methods Between July¿October 2014, treatment staff from 31 Australian AOD services participated in an online cross-sectional survey. In addition, a site contact at each service was interviewed to gather service related data. Results Overall, 362 AOD program staff participated (response rate¿=¿57%) and 62% estimated that client smoking status was recorded for the ¿majority or all¿ of their clients. About a third (33%) reported that they ¿always¿ provide verbal advice to their clients to quit smoking, 18% ¿always¿ offered free or subsidized NRT and 16% ¿always¿ followed-up to check on client quit progress. Thirty percent reported that the decision to provide SCC was made on a client by client basis and 26% offered SCC only when the client requested assistance. Government-managed services, age and gender of AOD program staff were significantly associated with the provision of SCC. Conclusion Most AOD program staff report that smoking status is recorded for the majority of their clients however, the frequency with which SCC practices are delivered is low and the decision to provide care is arbitrary.

Objectives: This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines. Methods: A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines. Results: 112 relevant apps were identified. The majority were of poor technical quality and only six ¿high-quality¿ apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated. Conclusions: In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

Background: Comprehensive smoke-free policy in the alcohol and other drug (AOD) setting provides an opportunity to reduce tobacco related harms among clients and staff. This study aimed to examine within AOD services: staff awareness of their service's smoking policy compared to the written policy document and staff and service factors associated with accurate awareness of a total ban and perceived enforcement of a total ban. Methods: An audit of written tobacco smoking policy documents and an online cross-sectional survey of staff from 31 Australian AOD services. In addition, a contact at each service was interviewed to gather service-related data. Results: Overall, 506 staff participated in the survey (response rate: 57%). Nearly half (46%) perceived their service had a total ban with 54% indicating that this policy was always enforced. Over one-third (37%) reported a partial ban with 48% indicating that this policy was always enforced. The audit of written policies revealed that 19 (61%) services had total bans, 11 (36%) had partial bans and 1 (3%) did not have a written smoking policy. Agreement between staff policy awareness and their service's written policy was moderate (Kappa 0.48) for a total ban and fair (Kappa 0.38) for a partial ban. Age (1 year increase) of staff was associated with higher odds of correctly identifying a total ban at their service. Conclusions: Tobacco smoking within Australian AOD services is mostly regulated by a written policy document. Staff policy awareness was modest and perceived policy enforcement was poor.

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Introduction: Tobacco remains the key modifiable risk factor for the development of a number of diseases, including cardiovascular disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis and cancer. Among priority populations, smoking prevalence remains high, smokers tend to relapse more often and earlier and fewer are able to sustain quit attempts. This systematic review provides an update on the literature. Areas covered: Twenty-four randomized controlled trials published from 2010¿2017, in English language, were identified after searching on Medline, Ovid, Embase and PsycINFO databases. Studies reported on the effectiveness of smoking cessation interventions among six disadvantaged groups known to have high smoking rates: (i) homeless, (ii) prisoners, (iii) indigenous populations, (iv) at-risk youth, (v) people with low income, and (vi) those with a mental illness. Narrative review and assessment of methodological quality of included papers was undertaken. Expert commentary: There is a growing evidence base of methodologically robust studies evaluating a variety of behavioural smoking cessation interventions for priority populations. Multi-component interventions and those examining behavioural interventions incorporating mindfulness training, financial incentives, motivational interviewing and extended telephone-delivered counseling may be effective in the short-term, particularly for smokers on low incomes and people with a mental illness.

Introduction: Electronic cigarette (e-cigarette) awareness, trial of e-cigarettes in the past 12 months, source and perceptions of safety and effectiveness was assessed within a disadvantaged sample of adult Australian smokers receiving welfare aid. Methods: A cross-sectional survey was administered to clients who smoke at two community service organizations in New South Wales, Australia from October 2013 to July 2014. E-cigarette awareness, trial in past 12 months, sources of e-cigarettes and perceptions of the safety and effectiveness of e-cigarettes to help people quit were assessed along with sociodemographic and smoking-related variables. Results: In total, 369 participants completed the survey (77% response rate). Awareness and trial of e-cigarettes were reported by 77% (n = 283) and 35% (n = 103) of the sample, respectively. E-cigarettes were most commonly obtained from friends/strangers followed by tobacco shops (tobacconists). Trying e-cigarettes in the past 12 months was significantly associated with positive perceptions of their safety (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1, 3.1) and effectiveness (OR = 1.9, 95% CI = 1.1, 3.2). Motivation to quit tobacco smoking was also significantly positively associated with positive perceptions of e-cigarette safety (OR = 1.2, 95% CI = 1.1, 1.4) and effectiveness (OR = 1.2, 95% CI = 1.0, 1.3). Conclusions: Rates of awareness and trial of e-cigarettes within a disadvantaged sample of Australian smokers are comparable to rates found within representative samples of the general Australian population. Previously trying e-cigarettes and higher levels of motivation to quit were associated with more positive perceptions of e-cigarette safety and effectiveness. Implications: This study demonstrates that socioeconomically disadvantaged smokers are aware of and accessing e-cigarettes in a country with relatively high restrictions covering e-cigarette sale and use.

Introduction and Aims: The aim of this study was to explore beliefs about tobacco dependence treatment from the perspective of staff and clients in addiction treatment settings.Design and Methods: A qualitative study was conducted between August and November 2013 using grounded theory methodology. Participants were recruited from four government-funded drug and alcohol services in a regional centre of New South Wales, Australia. Treatment centre staff (n=10) were interviewed using a semistructured interview guide and two focus groups (n=5 and n=6) were held with clients of the same treatment centres.Results: Both clients and staff wish to do more about tobacco use in addiction treatment services, but a number of barriers were identified. Staff barriers included lack of time, tobacco-permissive organisational culture, lack of enforcement of smoke-free policies, beliefs that tobacco is not a treatment priority for clients and that clients need to smoke as a coping strategy, and perceptions that treatment was either ineffective or not used by clients. Clients reported smoking as a habit and for enjoyment or stress relief, seeing staff smoking, nicotine replacement therapy unaffordability and perceptions that nicotine replacement therapy may be addictive, and inability to relate to telephone cessation counselling as barriers to quitting smoking.Discussion and Conclusions: Client and staff perceptions and attitudes about the treatment of tobacco, particularly those relating telephone support and nicotine replacement therapy, provided information, which will inform the design of smoking cessation programs for addiction treatment populations. [Wilson AJ, Bonevski B., Dunlop A., Shakeshaft A, Tzelepis F., Walsberger S., Farrell M., Kelly PJ, Guillaumier A. 'The lesser of two evils': A qualitative study of staff and client experiences and beliefs about addressing tobacco in addiction treatment settings. Drug Alcohol Rev 2015].

Objective: To describe self-reported inability to access health care and factors associated with lack of access among a socioeconomically disadvantaged group. Method: A cross-sectional survey with 906 adult clients of a large community welfare agency in New South Wales. Clients attending the service for emergency assistance completed a touchscreen survey. Results: Inability to access health care in the prior year was reported by more than one-third of the sample (38%), compared to the 5% found for the general population. Dentists (47%), specialists (43%) or GPs (29%) were the least accessible types of health care. The main reason for inability to access health care was cost, accounting for 60% of responses. Almost half (47%) the sample reported delayed or non-use of medicines due to cost. Increasing financial stress was associated with increased inability to access GP or specialist care, medicines and imaging. Higher anxiety scores were associated with inability to access health care, and with cost-related inability to access medicines and imaging. Conclusion: For disadvantaged groups, cost-related barriers to accessing care are prominent and are disproportionately high - particularly regarding dentistry, specialist and GP care. Implications: Improvements in health outcomes for disadvantaged groups are likely to require strategies to reduce cost-related barriers to health care.

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few studies have examined how high smoking prevalence groups respond to these warnings. This study explored how socioeconomically disadvantaged smokers engage with health risk and cessation benefit messages. Six focus groups were conducted over September 2012-April 2013 with adult clients of welfare organizations in regional New South Wales, Australia who were current smokers (n = 51). Participants discussed HWLs, plain packaging and anti-smoking television advertisements. Discussions were audio-taped, transcribed verbatim and analysed using thematic analysis. Highly emotive warnings delivering messages of negative health effects were most likely to capture the attention of the study participants; however, these warning messages did not prompt quit attempts and participants were sceptical about the effectiveness of cessation programmes such as telephone quitlines. Active avoidance of health warning messages was common, and many expressed false and self-exempting beliefs towards the harms of tobacco. Careful consideration of message content and medium is required to communicate the anti-smoking message to disadvantaged smokers who consider themselves desensitized to warnings. Health communication strategies should continue to address false beliefs about smoking and educate on cessation services that are currently underutilized.

Background: Technical and Further Education (TAFE) colleges are the primary provider of vocational education in Australia. Most TAFE students are young adults, a period when health risk behaviours become established. Furthermore, high rates of smoking, risky alcohol consumption, inadequate fruit and vegetable intake and insufficient physical activity have been reported in TAFE students. There have been no intervention studies targeting multiple health risk behaviours simultaneously in this population. The proposed trial will examine the effectiveness of providing TAFE students with electronic feedback regarding health risk behaviours and referral to a suite of existing online and telephone services addressing smoking, risky alcohol consumption, fruit and vegetable intake, and physical activity levels. Methods/Design: A two arm, parallel, cluster randomised trial will be conducted within TAFE campuses in New South Wales (NSW), Australia. TAFE classes will be randomly allocated to an intervention or control condition (50 classes per condition). To be eligible, students must be: enrolled in a course that runs for more than 6 months; aged 16 years or older; and not meet Australian health guideline recommendations for at least one of the following: smoking, alcohol consumption, fruit and/or vegetable intake, or physical activity. Students attending intervention classes, will undertake via a computer tablet a risk assessment for health risk behaviours, and for behaviours not meeting Australian guidelines be provided with electronic feedback about these behaviours and referral to evidence-based online programs and telephone services. Students in control classes will not receive any intervention. Primary outcome measures that will be assessed via online surveys at baseline and 6 months post-recruitment are: 1) daily tobacco smoking; 2) standard drinks of alcohol consumed per week; 3) serves of fruit consumed daily; 4) serves of vegetables consumed daily; and 5) metabolic equivalent minutes of physical activity per week. Discussion: Proactive enrolment to existing online and telephone services has the potential to address modifiable determinants of disease. This trial will be the first to examine a potentially scalable intervention targeting multiple health risk behaviours among students in the vocational training setting.

Background Adolescence and young adulthood is a time of risky health behaviour initiation and experimentation. Smoking, risky drinking, poor nutrition and physical activity, and a lack of sun protection behaviour, often become established in early adulthood. Levels of health risk behaviours occurring amongst tertiary education and training students and their preferences for types of on-campus health promotion programs were examined. Method A cross-sectional pen-and-paper classroom survey was conducted at one Sydney-based TAFE New South Wales Institute campus in May 2010. The survey assessed demographics, smoking, alcohol use, sun protection, nutrition, physical activity and health promotion program preferences. Results: Two hundred and twenty-four students participated (97% consent); the majority were aged 16-24 years (59%) and female (51%). Current smoking (35%), risky drinking (49%) and inadequate physical activity (88%) rates were high. Adequate vegetable intake (3.6%) and sun protection behaviours (5.4%) were low and 33% of students were overweight or obese. Popular health promotion programs included food and activity subsidies, practical skills classes and social outings. Conclusion Participation in health risk behaviours among this sample was high. The setting of tertiary education and workplace training represents an opportunity for early intervention into risky health behaviours among young people. So what? This study is the first to provide information on the prevalence of health risk behaviours and preferences for types of health promoting programs among students of an Australian community college. The results show that young adults regularly participate in multiple health risk behaviours, such as smoking, drinking, poor nutrition, physical activity and lack of sun protection. © 2013 Australian Health Promotion Association.