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Reducing Harm Article

A study of the use of free nicotine patches


by Indigenous people

Abstract Rowena G. Ivers


Objective: To assess use of free nicotine Menzies School of Health Research, Northern Territory University
patches by Indigenous people when offered
a brief intervention for smoking cessation, Melissa Farrington, Chris B. Burns
and to assess changes in smoking National Heart Foundation, Northern Territory division
behaviour at six months.
Methods: We conducted a pre and post Ross S. Bailie
study in three Indigenous communities in
Menzies School of Health Research and Flinders University,
the Northern Territory. Northern Territory Clinical School, Northern Territory
Results: Forty Indigenous smokers self-
selected to receive free nicotine patches
Peter H. D’Abbs
and a brief intervention for smoking
School of Public Health and Tropical Medicine, James Cook University,
cessation, and 71 chose the brief
and Queensland Health
intervention only. Eighty-four per cent of
participants were followed up; 14% of
participants could not be located. Fifteen
Robyn L. Richmond
per cent of the nicotine patches group (10% School of Public Health and Community Medicine, University of New South Wales
with CO validation) and 1% (CO validated)
of the brief intervention only group reported Eric Tipiloura
that they had quit at six months. Seventy- Tiwi Health Board, Northern Territory
six per cent of the nicotine patches group
and 51% of the brief intervention only group
had reduced their consumption of tobacco.

T
he prevalence of tobacco use is are no less likely to quit with free nicotine
No participant completed a full course of
approximately 80% for Indigenous patches than with those they have paid for
patches. One possible side effect – the
experience of bad dreams – was attributed
men 1 and 70% for Indigenous themselves.7
2
in one community to the person concerned women in the Top End of the Northern Few studies have assessed the use of
having been ‘sung’ or cursed. Territory. There are few reports of strategies nicotine patches by low-income groups,
Conclusions: Free nicotine patches might to reduce the prevalence of tobacco use although a randomised controlled trial (RCT)
benefit a small number of Indigenous among Indigenous people.3 of the use of nicotine patches by African-
smokers. Cessation rates for the use of Nicotine patches have a role in smoking Americans demonstrated a quit rate of 17%
both nicotine patches and brief intervention cessation. A Cochrane review of 108 trials at six months.8 Over-the-counter nicotine
alone were lower than those in other of nicotine replacement therapy (NRT) patches might not be accessible to minority
populations, possibly because the study concluded that nicotine patches increased populations because of socio-economic
was conducted in a primary care setting smoking cessation rates (OR 1.76),4 resulting constraints.9 In attempting to address this
and because of barriers to cessation such in a quit rate of 14% at one year. A meta- problem, some Indigenous health services
as widespread use of tobacco in these analysis of 17 studies of the use of nicotine have sold or subsidised nicotine patches;
communities and the perception of tobacco patches showed an abstinence rate of 22% others have distributed free patches. Form-
use as non-problematic.
(versus 9% for placebo) at six months.5 ative research involving a survey of 104
(Aust N Z J Public Health 2003; 27: 486-90)
Cessation rates are likely to be lower in health professionals working with In-
primary care than in other settings,4,6 possibly digenous people in the Darwin region in 1998
because smokers presenting to primary care showed that almost no Indigenous people had
are likely to be less motivated to quit than, tried NRT (unpublished report, R. Ivers,
for example, smokers volunteering for trials 2000).
or smokers recruited from hospitals. Smokers Brief interventions for smoking cessation

Submitted: March 2003 Correspondence to:


Dr Rowena Ivers, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811.
Revision requested: June 2003
Fax: (08) 8927 5187.
Accepted: August 2003

486 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 5
Reducing Harm Free nicotine patches and Indigenous people

also have an effect in reducing the prevalence of tobacco use.10-12 Table 1: Characteristics of 111 participants in
Advice on cessation is likely to assist an additional 2.5% of smokers intervention and control groups.
to quit.10 Characteristic Intervention Control p value
The first aim of this study was to assess the patterns of use of group group
free nicotine patches when offered to Indigenous people with a n (%) n (%)
brief intervention for smoking cessation. The second aim was to Gender
assess changes in smoking behaviour and attitudes six months Female 24 60 27 38 1 df, Yates
corrected
after access to free nicotine patches and/or a brief intervention for
Male 16 40 44 62 p=0.03
smoking cessation.
Age
30 years of age 13 33 43 61 1 df, Yates
or under corrected
Methods Over 30 years 27 67 28 39 p<0.01
This was a pre and post study of the use of free nicotine patches of age
and a brief intervention for smoking cessation by Indigenous people Tobacco consumption
in the Top End of the Northern Territory. We recruited participants Light smoker 7 18 28 39 1 df, Yates
(≤10 cigarettes corrected
from a consecutive sample of self-identified Indigenous smokers
per day)
presenting to participating health centres. The sample included Moderate or 33 82 43 61 p=0.02
some smokers who had been nominated by health professionals, heavy smoker
for example those who wished to access free nicotine patches. (>10 per day)

Health professionals who smoked were also asked if they wished Attitude to cessation
to participate in the study. Ready to quit 34 85 26 37 Fisher’s
Contemplation 6 15 27 38 Exact
Participating health centres were located in:
Pre-contemplation 0 0 17 24 2-tailed
• Community A – population 1,852,13 accessible by air and by
No response 0 0 1 1 p<0.01
road only in the dry season.
‘Tobacco use causes lung cancer’
• Community B – population 1,276,13 accessible only by air.
Agree 35 88 61 86 Fisher’s
• Community C – population approximately 350, located in an
Disagree or 4 10 9 13 Exact
urban centre. not sure 2-tailed
No response 1 2 1 1 p=0.77
Baseline visit
We recruited Indigenous smokers in August–December 2000.
Those with a history of ischaemic heart disease, cerebrovascular
disease, diabetes, or who were pregnant or breastfeeding were be used 24 hours a day. Each participant was given a one week
excluded from the trial because of concerns about side effects. We supply of nicotine patches, with directions to return to collect more
also excluded all of those under the age of 18. patches from the health centre.
The researcher and a local research assistant explained the study
(in local language if necessary), sought informed consent from Follow-up visit
smokers and then verbally administered a standard questionnaire Participants were followed up after six months. The research
in English to ascertain smoking behaviour, attitudes to tobacco team administered a follow-up questionnaire to assess the number
use (readiness to quit) and knowledge about tobacco. Subjects of patches used, changes in smoking behaviour (point prevalence
self-selected to participate in one of two groups; one group was of smoking status, validated by carbon monoxide (CO) breath test)
given a brief intervention for smoking cessation and nicotine and attitudes to tobacco use. The questionnaire also assessed side
patches, and the second group was given a brief intervention only. effects experienced and barriers to using nicotine patches.

Intervention
The brief intervention involved being given advice on quitting Results
(including being given advice on the health effects of tobacco use, Baseline visit
support in setting a quit date and counselling on cessation according One hundred and eleven Indigenous smokers were interviewed
to readiness to quit), being shown a flip-chart about tobacco and at the baseline visit. Of these, 26% were Aboriginal health workers.
being offered a pamphlet. The intervention took approximately Nineteen people (aside from the 111 participants) were excluded
five minutes to administer. The nicotine patches group was on the basis of the exclusion criteria specified above. Five
instructed in the use of nicotine patches according to the Indigenous smokers chose not to be part of the study. The nicotine
manufacturer’s instructions. The course consisted of six weeks of patches group contained 40 smokers and the brief intervention
21 mg patches, two weeks of 14 mg patches and two weeks of 7 only group contained 71 smokers. Table 1 shows the baseline
mg patches, a total of 10 weeks of treatment. The patches were to characteristics of the two groups.

2003 VOL. 27 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 487
Ivers et al. Article

Follow-up visit Barriers to cessation


Thirty-four (85%) of those in the intervention group and 59 Tobacco use was widespread in these communities. Smoking
(83%) of those in the control group were interviewed at the follow- was seen as the norm; it was a socially sanctioned activity. In at
up visit six months later; 16 participants could not be located, one least one of these communities, tobacco continued to play a role
was in mourning and one had died of a cause unrelated to the use in some traditional activities. Many participants said that they had
of nicotine patches. Thirty-one people in the nicotine patches group been unable to quit, even with patches, because of the constant
had used patches and eight had not. One participant in the brief presence of people smoking around them. Many lived in crowded
intervention only group had used patches that she had been given houses with other smokers; 86% lived with between two and 12
by a family member. Other participants in the NRT group smokers. However, there was no difference between the quit rates
commented that they had given patches to family or friends not in those with fewer smokers in the house and those with more
enrolled in the trial. smokers.
No participant had completed a full course of patches; the mean
number of patches used, as reported by participants, was five
patches (range 0-49 patches). Only six people said that they had Discussion
used more than seven patches, that is, 10% of the suggested course Study design
of treatment. Age, gender, and community of participants were As a result of self-selection, the treatment groups differed on
not related to the length of course of patches used. many baseline parameters (interest in using patches, age, sex,
tobacco consumption, readiness to quit, likely motivation to quit),
Changes in smoking status and
and this precludes any direct comparison of the impact of NRT
attitudes to smoking
and brief intervention on smoking behaviour and attitudes. The
Six (15%) of those in the nicotine patches group reported that
optimal design for such a study is likely to consist of a randomised
they had quit while one member (1%) of the brief intervention
controlled trial of the use of free nicotine patches in an Indigenous
only group had quit (assuming all those lost to follow-up contin-
setting, possibly using a clustered staggered RCT with
ued to smoke).4
randomisation by community. The study design was chosen after
We were not able to validate all participants’ smoking status
consultation with health professionals and community repre-
with CO monitoring. Seven of those in the intervention group
sentatives, who believed (perhaps erroneously) that a RCT was
(18%) and 14 of those participants in the control group (20%)
inequitable if some participants did not have access to NRT at the
declined, or were not able to use the CO meter. Two participants
same time as others.
who said that they had quit had elevated CO levels (³10ppm CO).
When only data from those who reported that they had quit and
Use of nicotine patches
had been CO validated to confirm non-smoking status was used,
Uptake of free nicotine patches was lower than anticipated. Nico-
four (10%) of those in the nicotine patches group and one mem-
tine patches cost approximately $32-35 in addition to freight costs
ber (1%) of the brief intervention only group had quit.
for a week’s supply; by comparison, a week’s supply of cigarettes
Seventy-six per cent of those in the nicotine patches group and
for a pack-a-day smoker cost $46-74. It appeared that there were
51% of those in the brief intervention only group reported that
other factors apart from the cost of nicotine patches that prevented
they had reduced their consumption of tobacco.
smokers from using NRT as an aid to quitting, which might have
There were no significant changes in readiness to quit in either
included a widespread perception that smoking was normal be-
the nicotine patch or brief intervention groups (Fishers’ Exact
haviour.
p=1.0 and 0.21 respectively); 38% of smokers in the nicotine
A number of people who were interested in trying nicotine
patches group and 29% of the brief intervention only group were
patches were excluded from the trial; many of these people might
less ready to quit after trying patches than they had been at the
have been suitable for nicotine patches under medical super-
baseline visit.
vision.4,14
Side effects
Twenty-nine per cent of those who had used patches had expe- Compliance
rienced bad dreams. Participants in one community commented Some participants had borrowed or given away nicotine patches;
that the traditional interpretation of bad dreams or nightmares this reflects a strong culture of sharing in traditional communities
was that they signified that a person was being ‘sung’ or cursed; and might indicate the difficulty of conducting experimental
some participants were consequently reticent to use patches. Other research in small communities. Diffusion of an innovation such
side effects included pruritis (21%), nausea (4%), palpitations or as nicotine patches is likely to have health benefits, but, if used
shakiness (7%), and tiredness (7%). Although the study was con- without seeking medical advice by those who are at higher risk of
ducted through the tropical wet season, 93% said that the patches suffering from side effects, might have detrimental effects. Sharing
stayed stuck on all or most of the time. Those who used more of NRT might also reflect a failure in the health professional-patient
than a week of patches were no more likely to have suffered from interaction regarding appropriate use of NRT.
side effects than those who used seven patches or less. Many participants failed to return to pick up more patches and

488 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 5
Reducing Harm Free nicotine patches and Indigenous people

no participant completed a full course of patches. The low rate of Side effects
completion of a treatment course is likely to have reduced the Many participants experienced side effects but few regarded
cessation rate. This might reflect selection of smokers who were them as serious. The concern over the traditional interpretation of
inappropriate for nicotine patches. bad dreams could be a significant barrier to use of nicotine patches
The study was conducted with minimal resources. If the study in the one community concerned. Twenty-one per cent experi-
was conducted with a full-time research worker who delivered enced pruritis, compared with 54% in a systematic review of other
nicotine patches to the homes of participants, the quit rate might studies of nicotine patches;4 this might have been because so few
have been higher, at least for motivated participants. However, people used patches consistently.
such a situation is unlikely to have been sustainable in the long
term given the financial constraints on these health services. The Barriers to cessation
heavy workload of health staff in these health centres and the A history of colonisation is likely to have contributed to the
pressure to provide health care for acute health problems made high prevalence of tobacco use in these communities; many older
the dispensing of nicotine patches a low priority. residents had taken up smoking when they were paid in tobacco.
Low employment rates and boredom may also have contributed
Changes in smoking behaviour to the high prevalence of tobacco use in these communities.
The quit rate at six months of 15% is lower than that demon- That smoking was seen as a normal part of life was a major
strated in a meta-analysis of the use of nicotine patches in other barrier to cessation, although the presence of smokers in the home
populations, which showed a quit rate of 22%.5 However, the quit did not appear to influence the likelihood of cessation, probably
rate was similar to that in inner-city African-Americans (17%).8 because the number of participants who did not live with other
The quit rate might be inflated as some participants reported that smokers was so small as to not show an effect. An external envi-
they had quit smoking but their CO measure was consistent with ronment that is conducive to quitting is critical to reduce the preva-
continued smoking. By comparison, a study that involved the lence of smoking. Other interventions that could be evaluated in
assessment of the validity of self-reported cigarette smoking in a this setting include community action to reduce the prevalence of
remote Indigenous community (but did not involve evaluation of tobacco use, harm reduction programs such as prevention of smok-
an intervention) found that self-report was adequate for assess- ing in enclosed public places, and broader community media and
ment of smoking status.15 education campaigns. Broader qualitative research on the role of
The low cessation rate in the NRT group is consistent with the tobacco in Indigenous societies may give some insight into the
intervention not being effectively delivered to or taken up by barriers to cessation.
smokers in the NRT group. The low cessation rates overall are
consistent with the intervention being of low intensity and being
delivered in a primary care setting4 compared with many other Conclusion
studies included in the Cochrane systematic review, which were The use of free nicotine patches by Indigenous people appeared
of high intensity and conducted with very motivated participants.6 to have a lesser effect on cessation rates at six months than in a
Health professionals who smoked were unlikely to quit even meta-analysis of trials of nicotine patches, but had a similar ef-
with patches. Four health professionals self-selected to the inter- fect to that reported in a study of African-Americans. The de-
vention group but failed to use the patches; they might have felt mand for nicotine patches among Indigenous smokers is unlikely
pressured to quit when they were not ready to do so. Indigenous to be large, but nicotine patches might suit a small number of
health professionals who smoked experienced the same barriers Indigenous people who are attempting to quit. More rigorously
to cessation as others in their community, but should neverthe- designed trials are required to assess the effect of nicotine patches
less be encouraged to deliver cessation advice to others. in this setting. Future studies of the use of nicotine patches in this
It is difficult to comment on whether the quit rate might have population should ensure careful screening of study participants
been higher if participants had to pay for patches. Few people in to ensure that they are committed to quitting and that participants
these communities had tried a consistent course of NRT prior to are supported to complete a full course of nicotine patches. More
the study, but few people tried a consistent course when patches generalised health promotion programs might be required to sup-
were freely available. port the small numbers of Indigenous people considering quit-
ting and to normalise cessation in this population.
Changes in readiness to quit
Although there were no significant changes in readiness to quit
in either group, some of those in the nicotine patches group were Acknowledgements
less ready to quit at follow-up, which indicated that a negative This project was given ethical approval by the Joint Institu-
experience with cessation might in fact make people move back- tional Ethics Committee of the Menzies School of Health Re-
wards through the stages of change, rather than encourage them search and Royal Darwin Hospital, and by the Northern Territory
to quit. University Human Ethics Committee. We would like to thank the
health boards of the participating communities for permission to

2003 VOL. 27 NO. 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 489
Ivers et al. Article

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