A survey of smoking prevalence and interest in quitting among social and community service organisation clients in Australia: a unique opportunity for reaching the disadvantaged

In 2009, the National Preventative Taskforce recommended that daily smoking prevalence in Australia be reduced to less than 10% by 2020 [1]. In recognition of high smoking rates among disadvantaged groups [2, 3], the taskforce acknowledged that "a special focus on working with and supporting disadvantaged groups and communities" would be needed to achieve this target [1]. There has also been increasing international recognition of the need for policies and strategies to increase access, affordability and use of smoking cessation services and treatments by disadvantaged smokers [2, 4, 5]. While the importance of a comprehensive population level approach to tobacco control cannot be overstated, in 2008 the US guidelines for tobacco dependence treatment called for research to explore the effectiveness of novel treatment delivery settings, including community-based settings, for reaching low socioeconomic status smokers and those with limited formal education [6]. One novel setting with considerable potential in Australia is social and community service organisations (SCSOs).

SCSOs are non-government, not-for-profit organisations that provide welfare services including financial and family counselling, temporary accommodation, food and material aid, and child and family support. They have existing contact with a large number of disadvantaged groups including the homeless, individuals with a mental illness, the unemployed and Aboriginal and Torres Strait Islanders [7], and are uniquely placed to provide smoking cessation support to disadvantaged smokers; they are able to address smoking in a holistic way alongside other issues faced by their clients, can provide personalised ongoing support, and have demonstrated growing interest in this opportunity via participation in programs such as the Cancer Council NSW's Tackling Tobacco initiative (see http://​www.​cancercouncil.​com.​au/​editorial.​asp?​pageid=​2210). Qualitative and quantitative work has established the acceptability of providing and receiving smoking cessation support in the SCSO setting [8, 9]. A small pilot study has also shown that providing training to staff of SCSOs develops confidence, skills and knowledge in addressing tobacco issues [10], overcoming some of the barriers identified in providing support in this setting [8]. While SCSO appear to be a promising setting for targeting disadvantaged smokers, no data exists to describe the prevalence of smoking and interest in quitting among clients attending SCSOs in order to make judgements about the potential reach of this approach.

The rate of current daily smoking at 53.5% was more than three times higher than the Australian population rate of 15.1% [15], and comparable to that documented in other severely disadvantaged groups such as those attending a psychiatric rehabilitation support service [16]. Daily consumption of cigarettes at 16.7 per day was slightly higher than the general population consumption of 13.9 cigarettes per day [17]. A considerably smaller proportion of participants were never smokers compared to the general population [17]. These data confirm that SCSO clients have rates of smoking and nicotine dependence similar to that of the most disadvantaged groups in Australia.

A high proportion of smokers had attempted to quit in the past year, adding further support to evidence that disadvantaged smokers have a desire to quit smoking that is comparable to the general population [18]. However, a relatively small proportion of participants reported using strategies known to increase quit success, including using nicotine replacement therapy and behavioural support. Few participants had contacted the telephone Quitline, and few showed interest in receiving this type of support. Alarmingly, over a third of respondents wanted help from the SCSO to access acupuncture and hypnosis, despite there being no evidence of the effectiveness of these types of support [19]. While the cost of nicotine replacement therapy is sometimes reported as a barrier to use amongst disadvantaged smokers and could explain this finding [20], further exploration of the reasons why disadvantaged smokers do not use other available services such as the telephone Quitline is needed. Such work would help inform the developed of strategies to increase engagement of disadvantaged smokers with evidence-based cessation interventions that will increase the likelihood of quit success.

More than half of smokers wanted support from the SCSO to quit, which highlights the potential of SCSOs to reach disadvantaged smokers. The Australian Council of Social Services reports that member SCSOs provided services to disadvantaged clients on more than 4.3 million occasions in 2009 [7]. Assuming a smoking rate of 62% and that 53% of clients would accept support, SCSOs could provide support to smokers on nearly 1.5 million occasions each year. SCSO client populations contain an over-representation of single parents, Aboriginal and Torres Strait Islanders, and individuals receiving social welfare payments [7], providing a unique way to access the most disadvantaged smokers in the community. It is unclear however whether utilization of support provided by SCSOs would be more or less than the 53% suggested by our data. Large randomised controlled trials are needed to examine the uptake of support by clients in this setting, and the effectiveness of this approach in increasing smoking cessation. A trial examining the efficacy of a client-centred, caseworker-delivered cessation support intervention is currently underway [21].

Smoking rates among clients accessing SCSOs are markedly higher than the general population. Given that a high proportion of smokers are interested in receiving quit support from SCSOs, the effectiveness of integrating the delivery of evidence-based support into care provided by SCSOs should be further explored.