Advancing treatment options for tobacco cessation, prevention and related illnesses, with particular reference to indigenous populations

Abstract

Despite the substantial progress made over the past decade, tobacco use is still a leading cause of preventable morbidity and premature mortality in the world. This thesis examined how to improve the uptake and success of smoking cessation and tobacco prevention interventions among some of the most prevalent tobacco users in Australia, being Indigenous populations and long-term tobacco users who have already developed tobacco-related illnesses. Although mainstream tobacco cessation programs have reduced population-level smoking, they have done little to close the gap between Indigenous and non-Indigenous populations. Therefore options specifically tailored for the Indigenous setting need to be considered. A meta-analysis of four culturally-tailored smoking cessation interventions in Indigenous populations (Chapter 4) produced some limited evidence of efficacy in favour of the interventions (p=0.03). Likewise, a similar evaluation for youth tobacco prevention found only two studies, limiting the ability to draw reliable conclusions (Chapter 5). Building on these findings, qualitative studies of Aboriginal Elders, key community stakeholders and health professionals revealed several barriers and facilitators for smoking cessation pharmacotherapy amongst Aboriginal Australian populations (Chapter 6). A national survey of current practice by Respiratory doctors and allied health professionals found similar results (Chapter 7). Finally a commissioned systematic literature review, found that combined pharmacotherapy and culturally-adapted interventions are effective in reducing tobacco prevalence (Chapter 8). Research in the Indigenous setting often poses methodological challenges, but options are available to overcome these problems (Chapter 9). Several pharmacotherapeutic options are available to aid long-term abstinence including varenicline tartrate, bupropion hydrochloride and nicotine replacement therapy (Chapter 10). However, amongst some populations where attitudes of nihilism and clinical indifference are common, the benefits of tobacco cessation are not considered worth the effort it would take to quit. Smoking cessation can result in improved treatment outcomes amongst lung cancer patients (Chapter 11) and quitting in later life can still reduce the risk of developing some smoking-related illnesses (Chapter 12). Following hospitalisation of current smokers due to a serious tobacco-related illness, a randomised controlled trial found varenicline tartrate plus Quitline counselling to be superior to Quitline counselling alone with 31.1% (n=61) and 21.4% (n=42) continuously abstinent respectively at 12-month follow-up (Chapter 13). Despite safety concerns of increased cardiovascular and neuropsychological events in acutely unwell people, none were identified amongst the 392 subjects recruited into the trial (Chapter 14). Finally a third Cochrane meta-analysis (Chapter 15) revealed that patients of health professionals trained in smoking cessation techniques were more likely to achieve smoking abstinence (p=0.03) compared to untrained health professionals. The evidence produced in this thesis suggests that with appropriate training and resources, health professionals working in Indigenous populations can facilitate smoking cessation and reduce the uptake of smoking. Translational research is needed to explore the most effective ways to achieve these outcomes and bridge the gap between resource development and implementation into policy and practice. Until a greater focus is placed on evidence translation, we cannot effectively advance treatment options for tobacco cessation, prevent uptake amongst youth and ultimately avoid tobacco-related illnesses.