Cancer Council NSW. Tackling Tobacco Program Report on Phase

Transcription

1 Cancer Council NSW Tackling Tobacco Program Report on Phase

2 Contents Executive summary... 5 Acknowledgements Introduction Section 1: Background Description and purpose Theoretical framework Management and staffing Key Result Areas Evaluation framework and plan Section 2: Tackling Tobacco Program areas Awareness raising and promotion Meetings and briefings with SCSO senior staff Seminars, workshops and conference presentations Sector newsletters Peer-reviewed publications Summary brochure Tackling Tobacco e-newsletter Information, publications and resources Information sheets Literature reviews Policy resources Casework resources Tackling Tobacco website Project development and support

3 Community Initiatives Scheme Peak agency projects Mental Health Coordinating Council peak agency project: the Breathe Easy Project Association of Childrens Welfare Agencies peak agency project: the Smoking Matters Project. 45 Other projects Training and education YAPA (Youth Action and Policy Association) Youth Workers Training Smoking Matters Training: peak agency project Breathe Easy Training: peak agency project Smoking Matters Project Follow-up Training YAPA/NAYH Training Salvation Army Recovery Services Staff Training Mission Australia: Michael Project Staff Training MHCC: Tobacco and Mental Illness Training Package Tackling Tobacco: Smoke-free Mental Health Project Smoking Care Projects (NSW and Blacktown) Research and data collection Youthblock Project: smoking-cessation project for disadvantaged young people AH&MRC Building Research Evidence to Address Aboriginal Tobacco Habits Effectively (Breathe Project) Focus groups: supports to quit smoking for NGO clients and workers Work with CHeRP Tackling Tobacco research agenda Surveys among social and community service organisations Data on smoking prevalence Partnerships and advocacy

4 Section 3: Progress on Key Result Areas Section 4: Learnings from the Tackling Tobacco Program What we have learned from the process of implementing the program What we have learned from the results of the program Section 5: Recommendations References Attachments

5 Executive summary Background of Tackling Tobacco In 2004, Cancer Council NSW (CCNSW) commissioned a study into the economic impact of a reduction in smoking in NSW. An incidental finding of that report was that the most disadvantaged households stood to gain the most from a fall in smoking. This led CCNSW to focus more attention on the issue of smoking and social disadvantage. As a result, the Tackling Tobacco Program was launched in The purpose of the Tackling Tobacco Program is to reduce smoking-related harm among the most disadvantaged population groups in NSW by working with, and through, non-government social and community service organisations (SCSOs). The program aims to build the capacity of the SCSOs to address tobacco issues and to support their clients to quit, and to make smoking care part of usual care. A defining feature of the program is that it presents smoking as a social justice issue and invites the sector to respond to it in those terms. The program seeks to obtain results in nine Key Areas, as outlined in the document Lifting the Burden: Tobacco Control and Social Equity Strategy July 2006 to June The program commenced with one full-time staff person. Currently, two full-time and two part-time staff are employed. Tackling Tobacco has attracted external funding from NSW Health for the Smoking Care Projects, which has funded the two part-time staff. Operational management of the program is provided by the Tobacco Unit Manager, with strategic guidance provided by the Director of Health Strategies, the CEO and an Expert Advisory Committee with members drawn from the community and public health sectors. Main areas of Tackling Tobacco activity and achievements The Tackling Tobacco Program is a complex strategy with multiple components, projects and activities. Some of the main activities and achievements are listed under six main headings below. 1. Awareness raising and promotion: Over 90 face-to-face meetings with leaders of SCSOs and/or their program managers have been held. More than 40 presentations to seminars, workshops and conferences have been given, including 14 oral conference presentations and 7 posters. Four journal articles have been published: two in community sector journals and two in refereed journals (one in partnership with the Centre for Health Research and Psycho-oncology (CHeRP)). Three other papers have been submitted to refereed journals. Tackling Tobacco e-newsletter is distributed twice yearly to over 1,100 contacts. 5

6 2. Information, publications and resources: Five information sheets on smoking and disadvantage, the benefits of quitting, and smoking and mental illness have been prepared. Two literature reviews have been completed: one on smoking and mental illness; the other on best practice smoking-cessation strategies for disadvantaged populations. Resources developed include an organisational policy toolkit (1,300 copies distributed), a group smoking-cessation program (250 copies distributed) and a casework resource to assist workers to provide quit support to individual clients (1,800 copies distributed). 3. Project development and support: More than 75 smoking-care projects involving more than 100 SCSOs have been supported by Tackling Tobacco, with funding from CCNSW and NSW Health. The funding grants have ranged from $4,000 to $110,000. An estimated 2,900 people have participated in some form of smoking-cessation support as part of the projects. These projects in SCSOs have generated changes in attitude, policy and ongoing practice regarding tobacco, which, in many instances, continue to have an effect after the funded projects have concluded. 4. Training and education: More than 1,500 social, community and health sector workers have participated in smoking-care training. Training packages have been developed for generalist and mental health settings. The offer of free training has been an important means to engage the interest and attention of the social and community services sector. Preliminary post-training evaluation of the Smoking Care Project (712 participants) showed that: o Nearly nine out of ten participants (87%) agreed that support to help people quit should be part of usual care o More than a third (39%) said they always record clients smoking status o Over three-quarters (77%) perceived the training about how to approach the issue of smoking with their clients as very useful, and 21% rated it as somewhat useful. 5. Research and data collection: Tackling Tobacco participated in the Aboriginal Health and Medical Research Council (AH&MRC) Breathe Project, researching the impact of tobacco-control workers within Aboriginal Community Controlled Health Services evaluation is pending. A NSW Community Sector Tobacco Survey in partnership with the NSW Council on Social Services (NCOSS), exploring attitudes, policy and practice regarding smoking, was completed in In partnership with CHeRP: o A series of focus groups to test the feasibility and acceptability of smoking care within social and community services was completed o A pilot intervention was trialled in a community service supporting people with mental health problems and is currently being written up. 6

7 A joint project with Sydney South West Area Health Service (SSWAHS) researching smoking care among marginalised young people was terminated due to staffing and program changes. 6. Partnerships and advocacy: Tackling Tobacco depends on forming partnerships with the social and community sector and health sector organisations. Important partnerships have been developed with the NCOSS, the Mental Health Coordinating Council (MHCC), the Association of Childrens Welfare Agencies (ACWA) and AH&MRC. Projects have been encouraged to work closely with local Area Health Service staff and CCNSW regional offices. Tackling Tobacco has advocated for action on issues of smoking and disadvantage through presentations at NSW Tobacco Network meetings, submissions to government inquiries, conferences and seminars, and membership of the Tobacco Issues Committee of Cancer Council Australia (CCA). Learnings from the Tackling Tobacco Program This section covers the key learnings from implementing Tackling Tobacco, as well as the main impacts of the program. Learnings from the process of implementing Tackling Tobacco: The social and community services sector is receptive to addressing tobacco issues: Generally, organisations were open to hearing about the issues and were receptive to the framing of tobacco as a social justice concern. Penetration was stronger in some community sector areas more than others: Mental health services have been the keenest participants, with some drug and alcohol programs and youth services also involved. The child and family sector has been less interested and involved. There are different views within tobacco-control circles about smoking and disadvantage: Not all of those working in the tobacco-control sector support efforts to reduce prevalence among disadvantaged smokers. There is little awareness within tobacco-control circles of the potential role the community sector could play in addressing smoking among the most disadvantaged. Moreover, there is a failure to differentiate between low-income and blue-collar smokers and those marginalised populations who face multiple disadvantages, from whom the bulk of clients within social and community services are drawn, and who have the highest smoking rates of all. 7

8 Provision of training is necessary but insufficient by itself: Offering free training is an important way to attract and engage organisations. Multiple strategies including providing casework resources, policy support and engagement of leaders are needed as well as training, to secure lasting practice change. It is important to maintain support for the practice of smoking care: In conducting their own smoking-care projects, workers have become convinced that this work is relevant, beneficial and achievable. Learnings from the results of Tackling Tobacco: Social and community service organisations can do this work: Results from multiple projects show that organisations do come to see this work as important. Workers within social and community services can gain the confidence and knowledge to address smoking with clients, they are able to support clients to quit using counselling and nicotine replacement therapy (NRT), and this work can be integrated into usual care of community sector organisations. Beliefs that disadvantaged people are not interested in quitting and/or are not able to quit, have been challenged: The majority of projects have found that some clients are interested in quitting. Clients have been able to quit or substantially cut down their smoking. This experience has changed the views of social and community sector workers. Access to free NRT is important in encouraging clients to have a go at quitting: The cost of and access to NRT is a barrier to quitting. Having free NRT available provided workers with something tangible to offer clients and was an incentive for clients to take part in a quit program. Free NRT was seen by many social and community service workers as being essential for people with mental health problems. Clients who quit or cut down their smoking experienced real benefits: Where clients were able to quit smoking, this often brought real and immediate improvements to their quality of life, made them feel better, allowed them to have more money and led to their being able to engage in a range of social and recreational activities. Cutting down their smoking also provided clients with some of these gains. There were few negative effects of providing smoking care: Very few problems were reported. One project recorded opposition from clients and staff to a no-smoking policy. No projects reported worsening symptoms among people with mental illness. There were no reports of adverse effects from use of NRT. The majority of organisations reported that clients and staff liked the projects. The program has contributed to a change of culture around smoking: Projects contributed to a change in attitudes and practice within participating programs. These changes sometimes spread to other parts of the host organisation. Several organisations revised their policies on smoking. These changes may well affect future practice and a new generation of clients and workers. 8

9 The Be Smoke Free Program has led to a culture of support at The Wayside Chapel, where quitting is on the agenda and all are welcomed and encouraged to participate (Staff person, Wayside Chapel) More work is required to consolidate the gains that have been made: While there is evidence of a change regarding smoking, this has not yet translated into consistent smoking-care practice. More work is required to embed smoking care in the organisations reached so far, and to engage the organisations we have not yet reached. 9

10 Recommendations That the Tackling Tobacco Program continue and that its reach within the NSW social and community sector be extended The program has had an impact on the attitude, policy and practice within the organisations it has reached to date, but this represents a relatively small proportion of the total sector. Strategies to extend the reach of the program within the NSW social and community services sector should be identified and implemented in the next phase. These may include focusing on large organisations, working intensively subsector by subsector, integrating smoking care into government-funded human and community services programs, and developing an accreditation program, like the SunSmart program for sun protection of children in primary schools and early childhood centres. That CCNSW advocate to the Commonwealth Government and other states for greater attention and action on the issue of smoking and disadvantage Tackling Tobacco has demonstrated that the approach of engaging the social and community service sector to address tobacco is feasible. CCNSW should use this experience to urge the Commonwealth Government to take the lead in a national approach to reducing prevalence among highly disadvantaged populations. CCNSW should seek to develop strategic alliances in this cause for example, with Australian Medical Association, the Public Health Association of Australia, the College of Physicians and the Centre for Behavioural Research in Cancer. That CCNSW conduct a more detailed analysis of the size and make-up of the social and community services sector in NSW A more systematic approach to the social and community service sector in NSW requires better information on the organisations that comprise it. CCNSW should seek to develop a better working knowledge of the sector for example, by obtaining member databases from a few key organisations and talking to their leaders. That Tackling Tobacco continue to engage senior social and community sector leadership in support of the program Currently, the program has had mixed success in engaging the highest levels of leadership in the sector. In the next phase, CCNSW should work more intensively to engage the support and active involvement of organisational and sector leaders. A sector think tank and/or conference are strategies to consider toward this end. That Tackling Tobacco collect and make better use of data on program reach and impacts Good-quality data is necessary to determine the effectiveness of the program. In the next phase, Tackling Tobacco should identify and collect data on the most important performance measures. Effort should be made to disseminate these findings widely within the social and community, public health and tobaccocontrol sectors. 10

11 That CCNSW seek other sources of funding for the Tackling Tobacco Program In order to place the program on a more secure footing, external sources of funding should be pursued. The range of State Government departments whose objectives overlap with those of Tackling Tobacco should be approached, alongside community and philanthropic sources. CCNSW should seek the support of social and community sector leaders for this task. That Tackling Tobacco continue the provision of training as a core program element Training is an important means to increase the social and community service sector s capacity to address tobacco issues. The offer of free training has helped prompt the interest and involvement of organisations that may still not see addressing tobacco as a priority. The capacity to offer free training should be retained and expanded. Tailored training for other subsectors for example, drug and alcohol should be developed. That CCNSW continue to advocate for access to affordable NRT for disadvantaged groups Easy access to affordable NRT is an important means to encourage disadvantaged people to make a quit attempt. Organisations working with people with severe mental illness have said it is essential. CCNSW should continue to explore and advocate for the most effective mechanisms to make NRT available to disadvantaged groups. CCNSW should seek to build alliances with influential bodies such as the Australian Medical Association and the National Preventative Health Agency in this task. That CCNSW work to secure better-quality data on smoking prevalence among disadvantaged groups It will not be possible to assess the effectiveness of strategies to reduce smoking among the most disadvantaged population groups without better-quality data. CCNSW is not in a position to drive this task. Such data is best collected at a national level, and requires CCA or a similar national body to take leadership on this task. CCNSW should seek strategic alliances to this end and advocate for it through its networks and in relevant state and national forums. That CCNSW expand its promotion of the issue of smoking and disadvantage with the tobacco control, media and public sectors Opinion on the need for attention to smoking and disadvantage within tobacco-control circles is divided. CCNSW should continue to speak out on this issue through groups such as the Tobacco Network, the CCA Tobacco Issues Committee and other forums. In addition, CCNSW should seek to more actively stimulate public consideration and discussion of these issues though selected media for example, through articles, op ed pieces, and through dissemination of research and project findings. 11

12 Acknowledgements Many people and organisations have contributed to the Tackling Tobacco Program since its inception in late Cancer Council NSW would like thank members of the Tackling Tobacco Expert Advisory Committee, who have generously given of their time and knowledge to guide the program s development. We also owe members of both the NSW and the Blacktown Smoking Care Projects advisory committees our gratitude. We greatly appreciate the role played by our all our community sector partners and the many organisations and staff who have hosted projects. Their enthusiasm and commitment to the welfare of the people with whom they work have been inspiring. In particular, we would like to thank the NSW Council of Social Service, the Association of Childrens Welfare Agencies, the Mental Health Coordinating Council and the Aboriginal Health and Medical Research Council. Without their openness to addressing smoking and disadvantage, and their collaboration in projects, training and research, the program would have been much less effective. We thank our colleagues in the Centre for Health Research and Psycho-oncology for their work on many Tackling Tobacco research projects and their unfailing readiness to provide advice and feedback. Their expert knowledge and support have been much appreciated. Our thanks go also to our colleagues in Cancer Council regional offices who have promoted and supported Tackling Tobacco activity in their areas. We would like to acknowledge the contribution of NSW Health and the Centre for Health Advancement in funding the NSW and the Blacktown Smoking Care Projects, and the support they have provided in administering those initiatives. Finally, our thanks go to all the staff, volunteers and clients who saw in Tackling Tobacco a cause that matters, and took the step to get involved. 12

13 Introduction Over the past 30 years smoking rates among the general population have declined substantially in Australia. That is to be celebrated. However, smoking rates among groups facing severe and multiple disadvantages remain much higher. It is these, already vulnerable groups, who bear the greatest burden of tobacco related illness. Equally significantly, smoking imposes a heavy financial burden upon them, reducing the funds available for essentials and other means to improve their quality of life. In response to this disparity, in 2006, Cancer Council NSW instigated the Tackling Tobacco Program. The program aimed to reduce smoking related harm among the most disadvantaged groups in NSW. It sought to achieve this aim by working with, and through, the social and community service organisations already in contact with those groups. Essentially, Tackling Tobacco had two main purposes: to get smoking on the agenda of social and community service organisations and; to work with organisations to build their capacity to address tobacco issues and support their clients to quit. A distinctive feature of the Tackling Tobacco Program is that it presented smoking as a social justice issue. The program took the view that it was not acceptable to celebrate the reduction in smoking among the general population but leave our most disadvantaged citizens with high smoking rates and to suffer the terrible consequences that followed from that fact. This document reports on the implementation of the Tackling Tobacco Program over its first five years of operation, The report is divided into five sections. It begins by providing background on the program including the purposes of Tackling Tobacco, its staffing and operational management and key result areas. Section 2 describes the main areas of activity within the program. Section 3 summarises the program s achievement according to the nine key result areas. Section 4 outlines what has been learned from the program, both in terms of its process and the results that have been achieved. The final section makes recommendations for priorities for the next phase of the Tackling Tobacco Program. 13

14 Section 1: Background In recent years, Cancer Council NSW (CCNSW) has developed a concern about the correlation between smoking and disadvantage evident in the high rates of smoking among very disadvantaged population groups. In 2004, CCNSW commissioned a study into the economic impact of a reduction of smoking in NSW, including an assessment of the differential impacts of a drop in smoking on groups of lower socioeconomic position. Findings indicated that an overall reduction in smoking would result in a net economic benefit to NSW and that it is the poorest households who would stand to gain the most from reduced smoking. 1(p4) This finding, when added to the known health impacts of smoking, made it clear that it was those already very disadvantaged groups with very high smoking rates who bore the greatest burden of tobaccorelated harm in NSW. This work added a new dimension to Cancer Council s view of tobacco, no longer seeing it exclusively as a public health issue but also as a social justice issue that called for action. To direct this action, a literature review and formative research 2 with leaders in the social and community services sector on the topic of tobacco control and social equity was commissioned, and a strategy to engage the community sector around smoking was developed (see Attachment 1 for a report on the formative research). This strategy focused on engaging the non-government social and community services sector. There was a range of reasons for this. They had existing connections with the most disadvantaged population groups in NSW; they were familiar with and skilled in promoting positive behavioural change among their clients; organisations commonly had a commitment to fairness and equity for their clients; and they were flexible and responsive, being able to adopt innovative practice relatively quickly. The strategy document, Lifting the Burden: Tobacco Control and Social Equity Strategy July 2006 to June 2011 (TCSES) (Attachment 2), was finalised and launched in partnership with the NSW Council of Social Service on 30 October The document outlined nine Key Result Areas to be the focus of program activity. The Tobacco Control and Social Equity Strategy was renamed the Tackling Tobacco Program in Description and purpose The Tacking Tobacco Program was conceived as a five-year strategy for the years 2006 to A defining feature of the program was that it reframed smoking as a social justice issue and urged the community and tobacco-control sectors to respond to it in those terms. The Tobacco Control and Social Equity Strategy stated: Cancer Council does not believe that it is either right or fair that already vulnerable groups bear a disproportionate share of the harmful effects of tobacco use. Given the extent of tobacco use and its effect in shortening and impoverishing human life, reducing smoking among the most disadvantaged is an urgent social justice issue and one that demands sustained action. This strategy is our contribution to that effort. 3(p7) 14

15 The ultimate purpose of the Tackling Tobacco Program was to reduce tobacco-related harm among the most disadvantaged population groups in NSW by working with non-government social and community service organisations (SCSOs). The program focused on: Increasing the capacity of the social and community service sector to address tobacco issues Creating quit-friendly service environments Assisting clients of social and community service organisations interested in quitting. The program utilised a theory of change model to describe how its strategies were expected to translate into its intended outcomes (see Figure 1.1). 15

16 There are four levels of inputs and outcomes: program outputs, intermediate results, program outcomes and final outcomes: The program outputs are the main strategies or areas of activity, including raising awareness of tobacco issues, developing resources and conducting training, and these will be described in more detail in a later section. 16

17 The intermediate results relate to increased awareness of the links between smoking and disadvantage, more positive attitudes among organisations to addressing smoking at a number of levels, and an increase in workers knowledge, skills and confidence to provide quit-smoking support to clients. The program outcomes encompass changes in staff, organisational and client behaviour, as well as organisational level changes in culture, attitudes and policy and practice (for example, policies on staff smoking with clients, designated smoking areas and provision of quit support to staff and clients; and practices such as assessment of clients smoking, provision of quit-smoking information to clients and provision of or access to smoking-care training for staff). The final outcomes include a reduction in smoking-related harm among disadvantaged populations and an increase in physical, social and material wellbeing. Theoretical framework The development and implementation of the Tackling Tobacco Program has drawn from diffusion of innovation theory a conceptual framework that examines factors associated with successful implementation of an innovation in a setting and the extent to which the innovation can then be transferred to other settings. 4 This theory is relevant to the Tackling Tobacco Program, given that addressing smoking has not traditionally been a priority within non-government SCSOs. Anecdotal evidence indicates SCSOs have had a permissive attitude to smoking, or seen it as a minor harm. Diffusion of innovation theory suggests that characteristics of the setting in which innovations are applied influence success or failure. 4-6 The general principle is that innovative projects do not survive in hostile settings. Taking care to select and prepare settings that welcome or are at least open to the initiative is important, as is finding ways to sustain support over time. Having the active commitment of key leaders and decision-makers in the host setting is crucial. They must be convinced of the need for change and the value of the new practice. Finally, researchers in this area note that resistance is a normal response to the change of existing ways of working. It is important to anticipate and address objections if the innovation is not to stall. Research on integration of tobacco control into drug and alcohol service settings has emphasised the need for multi-component interventions. 7 Single component strategies are not potent enough to secure lasting change: more intense, multi-strategy projects are required. Tackling Tobacco sought to take account of this theory in the way the various program elements were formulated and implemented. 17

18 Management and staffing Overall, operational management of the program was provided by senior staff within CCNSW, and guidance and direction was provided by an Expert Advisory Committee. Expert guidance Membership of the program s Expert Advisory Committee was drawn from SCSOs and peak agencies, as well as from among persons with substantial public health expertise. The committee was chaired by CCNSW CEO, Dr Andrew Penman. Meeting twice a year, the committee s purpose has been to provide expert guidance, constructive criticism and strategic advice about the development and implementation of the Tackling Tobacco Program (See Attachment 3 for the committee s membership and terms of reference). Staffing The staffing of the Tackling Tobacco Program included: Senior Program Coordinator (full-time) July 2006 current Program Coordinator (full-time) May 2008 current Project Officer: NSW Smoking Care (three days) February 2010 current Project Officer: Blacktown Smoking Care (three days) February 2010 current Day-to-day operational management of Tackling Tobacco has been provided by the Tobacco Control Unit Manager, and the Tobacco Control Unit Project Coordinator also provided invaluable support in program administration and communications. 18

19 Key Result Areas The strategy document for the Tackling Tobacco Program outlined nine Key Result Areas: 1. Better awareness and understanding of smoking risks among social service agencies and their staff 2. Building the capacity of social service agencies to contribute to tobacco-control efforts 3. Better awareness and understanding of smoking risks among socially disadvantaged population groups 4. Action research to identify practical strategies to support tobacco control in specific population groups 5. Better smoking-cessation support for low-income and socially disadvantaged groups 6. Fostering harm-limiting behaviour among socially disadvantaged smokers 7. Better integration of tobacco control into responses to social disadvantage 8. A better evidence base in relation to tobacco control and social disadvantage 9. Supporting policy and legislative initiatives to address social disadvantage and enhance tobacco control. Evaluation framework and plan In early 2008, CCNSW worked with ARTD Consultants to produce a comprehensive evaluation plan for the program. As part of the development, consultations were conducted with some selected representatives of community sector agencies, peak organisations, and government and non-government members of the NSW Tobacco Control Network. The full document Evaluation Framework and Plan for the Tobacco Control and Social Equity Strategy can be found in Attachment 4. 19

20 Section 2: Tackling Tobacco Program areas The Tackling Tobacco Program is a complex strategy with multiple components, projects and activities. In order to better describe its scope and diversity, it is useful to categorise program elements under six headings: 1. Awareness raising and promotion 2. Information, publications and resources 3. Project development and support 4. Training and education 5. Research and data collection 6. Partnerships and advocacy. Awareness raising and promotion Raising awareness about the links between smoking and disadvantage, and persuading organisations to see it as an important issue to address, were crucial tasks, especially in the early days of the program. It was also a prerequisite for persuading the community sector to take part in program activities. The Tackling Tobacco Program used a variety of means to engage social and community sector organisations (SCSOs) and raise their awareness about smoking and disadvantage. Some of the main methods were: Meetings and briefings with SCSO senior staff Seminars, workshops and conference presentations Sector newsletters Peer-reviewed publications Summary brochure Tackling Tobacco e-newsletter. Meetings and briefings with SCSO senior staff One strategy to engage organisations with Tackling Tobacco was to seek meetings with SCSO senior staff. Between 2006 and 2010, the Tackling Tobacco Program staff conducted formal, face-to-face briefings with leaders of more than 90 community sector organisations or managers of their programs. These included 19 peak organisations (which generally do not provide direct services to clients). Staff also briefed eight interagency and community network meetings. Each of the latter was attended by representatives of multiple organisations (approximately representatives). In addition, as part of the Smoking Care Projects (NSW and Blacktown), Tackling Tobacco held individual briefings with more than 30 organisations, and spoke at interagencies attended by representatives of a further 75 organisations. 20

21 Seminars, workshops and conference presentations Promotion of the program was also achieved through workshops or seminars hosted with partner organisations in the community sector. For example: A presentation to all the program managers and coordinators of UnitingCare Burnside (approximately 60 people) in 2007 A Smoking and Disadvantage workshop conducted with the NSW Council on Social Services (NCOSS) in 2008, which attracted approximately 30 attendees from a range of services and government departments. Tackling Tobacco Program staff have also spoken at conferences to raise awareness of smoking and disadvantage, shared project-related findings and engaged organisations in Tackling Tobacco activities. These presentations include the Youth Action and Policy Association Conference (2007), the Public Health Association of Australia conference (2009) and the Oceania Tobacco Control Conference (2007 and 2009). In the last four years, Tackling Tobacco staff have presented at more than 40 workshops, seminars and conferences, with a total of more than 1,000 participants. (Note that this estimate excludes those conference presentations with an asterisk in the list that follows.) Conference presentations Below is a list of conference presentations on the Tackling Tobacco Program. The list covers only invited presentations to formal conferences. The name of the main presenter is in bold. (i) Conference oral presentations *Tang A, O Brien J. Reframing smoking: tobacco control and social equity strategy. Paper presented at: Oceania Tobacco Control Conference; 2007 Sep 4-7; Auckland, New Zealand. O Brien J, Tang A, Oakes W. Responding to tobacco and disadvantage: findings and implications from focus groups among inner Sydney community services. Paper presented at: Oceania Tobacco Control Conference; 2007 Sep 4-7; Auckland, New Zealand. *Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. Smoking cessation for disadvantaged clients of community welfare services: a qualitative study of barriers and opportunities. Paper presented at: National Heart Foundation Conference; 2009 May 14-16; Brisbane, Australia. *Bryant J, Bonevski B, Paul C. A methodological review of interventions aimed at reducing smoking among the socially disadvantaged. Paper presented at: National Heart Foundation Conference; 2009 May 14-16; Brisbane, Australia. O Brien J, Hull P. Thank you for asking engaging the community sector to reduce smoking-related harms among disadvantaged populations. Paper presented at: Public Health Association of Australia Conference; 2009 Sep 27-29; Canberra, Australia. 21

22 O Brien J, Hull P, Oakes W. Tackling Tobacco Program: engaging the community sector to reduce smoking-related harm among disadvantaged populations. Paper presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. Hull P, O Brien J, Oakes W. Working with the community sector to reduce tobacco harms amongst the disadvantaged: findings from the Cancer Council NSW s Tackling Tobacco Program. Paper presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. Bonevski B, Bryant J, Paul C. Paying the poor to quit: perceptions about financial incentives for smoking cessation.paper presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. It s got a hold on me : an exploration of barriers and facilitators to smoking among disadvantaged Australian smokers. Paper presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. *Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. Tackling Tobacco: community social services as a setting for providing cessation support to disadvantaged smokers. Paper presented at: Behavioural Research in Cancer Control Conference; 2010 Apr 14-16; Fremantle, Australia. *Bryant J, Bonevski B, Paul C. A meta-analysis of the effectiveness of behavioural cessation interventions in selected disadvantaged groups. Paper presented at: Behavioural Research in Cancer Control Conference; 2010 Apr 14-16; Fremantle, Australia. *Bonevski B, Bryant J, Paul C. Paying the poor to quit: perceptions about financial incentives for smoking cessation. Paper presented at: Behavioural Research in Cancer Control Conference; 2010 Apr 14-16; Fremantle, Australia. *Bowman J, Bonevski B., Richmond R. Addressing smoking cessation in challenging settings. Symposium: Moving away from cigarettes as portable therapy for smokers with mental health problems: translating evidence from public health, clinical and training settings into policy. Paper presented at: 12 th Annual Meeting of the Society for Research on Nicotine and Tobacco (SRNT) Europe; 2010 Sep 6-9; Bath, United Kingdom. *Williams K, Moore R, Gardoll M, O Brien J. Building capacity in community services to tackle smoking among disadvantaged groups: the Smoking Care Project. Paper presented at: Australian Health Promotion Association Conference; 2011 Apr 11-14; Cairns, Australia. (ii) Conference posters Geike A. The Smoking Matters Project. Poster presented at: Association of Childrens Welfare Agencies Conference; 2008 Aug 18-20; Sydney, Australia. Ahasan N, Dunkerley N, O Brien J, Perusco A. Wesley Mission Sadleir Pilot Tobacco Project: revolutionising smoking norms within a residential drug rehabilitation setting. Poster presented at: Population Health Congress; 2008 Jul 6-9; Brisbane, Australia. 22

23 Bryant J, Bonevski B, Paul C. A weak rudder on the ship of disadvantage: a meta-analysis of the effectiveness of smoking-cessation research with disadvantaged smokers. Poster presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. The potential of community welfare organisations for delivering tobacco-cessation strategies to disadvantaged smokers. Poster presented at: Oceania Tobacco Control Conference; 2009 Oct 7-9; Darwin, Australia. Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. The potential of community service organisations for delivering smoking-cessation support to disadvantaged smokers. Poster presented at: 12 th Annual Meeting of the Society for Research on Nicotine and Tobacco (SRNT) Europe; 2010 Sep 6-9; Bath, United Kingdom. Bonevski B, Bryant J, Paul C, O'Brien J, Oakes W. Addressing social inequalities in smoking by partnering with community social services: the Tackling Tobacco Research Project. Poster presented at: 12 th Annual Meeting of the Society for Research on Nicotine and Tobacco (SRNT) Europe; 2010 Sep 6-9; Bath, United Kingdom. Hull P, O Brien J, Salmon A, Rayson D. Much needed, long overdue: working with community service organisations to tackle tobacco amongst disadvantaged smokers. Poster presented at: Australian Health Promotion Association Conference; 2011 Apr 11-14; Cairns, Australia. Sector newsletters Placing short articles in peak agency newsletters was a means to inform SCSOs about Tackling Tobacco issues and initiatives. Short articles were written for several newsletters and sector journals, including those of the NSW Council of Social Service (NCOSS) and the Youth Action and Policy Association. Longer articles have been published in sector journals such as Of Substance (drug and alcohol sector) and Developing Practice (child and family sector). Peer-reviewed publications Publications for peer-reviewed and other publications based on Tackling Tobacco research and other projects have been prepared. Some have been accepted for publication and others are being considered or are still to be finalised. Published papers O Brien J. Tackling Tobacco: reframing smoking and the role of community service organisations in reducing smoking related harm. Developing Practice: The Child Youth and Family Work Journal. 2007;18: Geikie A. Unlocking the untapped potential of addressing tobacco use in community service organisations. Developing Practice: The Child Youth and Family Work Journal. 2009;24:50-6. O Brien J, Geikie A, Jardine A, Oakes W, Salmon A. Integrating smoking care in community service organisations to reach disadvantaged people: findings from the Smoking Matters Project. Health Promot J Aust. 2010;21:

24 Bryant J, Bonevski B, Paul C, O Brien J, Oakes W. Delivering smoking-cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organisations. Health Educ Res. 2010;25: Submitted papers Bryant J, Bonevski B, Paul C, O Brien J, Oakes. A qualitative study of barriers to quitting among disadvantaged Australian smokers. Submitted to BMC Public Health. Bonevski, B., O Brien, J., Frost, S., Yiow, L., Oakes, W. Disadvantaged people who smoke should receive help to quit: a survey of community service organisation smoking policies, practices and attitudes. Submitted to Tobacco Control. Bryant J. Bonevski B, Paul C, Lecathelinais, C. Assessing smoking status in disadvantaged populations: is computer administered self report an accurate measure? Submitted to Nicotine and Tobacco Research. Planned papers (yet to be submitted) A number of other papers are planned, including a paper on the Community Initiatives Scheme (CIS) plus two other papers arising from Tackling Tobacco research work conducted by the Centre for Health Research and Psycho-oncology (CHeRP). In addition, staff of CHeRP and Tackling Tobacco have been invited to contribute two separate papers to a special issue of Drug and Alcohol Review on Tackling tobacco in socially disadvantaged groups: time for action. This edition will be published in the second half of Its aim is to showcase developments in the understanding of ways to reduce the high smoking rates in socially disadvantaged groups evident in most developed countries. Summary brochure In 2009, a summary Tackling Tobacco brochure was produced to outline the program (Attachment 5).The brochure has been used in meetings, briefings, presentations and conferences, and distributed following phone or requests. 24

25 Tackling Tobacco e-newsletter In 2009, Tackling Tobacco staff recognised the need for an electronic newsletter to be distributed to their increasing list of contacts. The newsletter that was developed contained stories and updates from Tackling Tobacco projects, comments on policy issues, examples of latest research and links to new resources. The newsletter is produced two to three times a year and is currently sent to 1,150 contacts on the Tackling Tobacco contact database. 25

26 Image: Tackling Tobacco newsletter September

27 Information, publications and resources A range of Tackling Tobacco resources has been developed to engage community organisations and support changes to policy and practice. These include: Information sheets Literature reviews Policy resources Casework resources Tackling Tobacco website. Information sheets Tackling Tobacco information sheets were developed in partnership with key social and community sector organisation (SCSO) partners through the Smoking Care Resources and Training Collaboration (SCRATC). This group was made up of representatives from CCNSW, the Association of Childrens Welfare Agencies (ACWA), the Mental Health Coordinating Council (MHCC) and NSW Health. This group conducted an informal audit of available information resources and created several new documents. These were made available on the Tackling Tobacco and partner organisations websites. The documents are entitled: The relationship between smoking and disadvantage and what community services can do The impacts of smoking and the benefits of quitting Smoking and your mental health Supporting someone with a mental health problem to address their smoking Information for health professionals: smoking and mental health. In addition, a longer paper on the relationship between smoking and financial stress was developed. All these documents can be found in Attachment 6. 27

28 Literature reviews The program aimed to contribute to better knowledge about the relationship between smoking and disadvantage, and the factors that lead to take-up, maintenance and cessation of smoking among disadvantaged groups. To address this requirement, two literature reviews were commissioned: Ragg M, Ahmed T. Smoke and mirrors: a review of the literature on smoking and mental illness. Tackling Tobacco Program Research Series no. 1. Sydney: Cancer Council NSW; (Attachment 7) Wise M, Hickey K, Palmer J. Taking action: a review of the literature on smoking programs among six special populations. Tackling Tobacco Program Research Series no. 2. Sydney: Cancer Council NSW; Around 700 copies of Smoke and Mirrors have been distributed, and anecdotal feedback suggests that the review has played an important role in challenging some common but largely unfounded beliefs about smoking and mental illness. NSW Health has subsequently funded Cancer Council NSW to work with consultants RaggAhmed to educate mental health professionals about smoking and mental illness, and to more actively address smoking among their patients. The second literature review is being updated for publication. A summary document based on it and on cessation research in the general population was produced in 2008, entitled Clearing the Smoke: best practice smoking cessation strategies for people with multiple disadvantages (Attachment 8). More than 2,000 copies of this resource have been distributed. 28

29 Policy resources Policy toolkit Encouraging SCSOs to develop their smoking-related policies was an important goal of the Tackling Tobacco Program. However, few, if any, resources existed to assist in that task. In 2008, a Tackling Tobacco resource, Addressing Smoking in Community Service Organisations: a policy toolkit, was produced (see Attachment 9). It contains: Information on smoking and disadvantage Main areas that policy on smoking should address Step-by-step guidance for developing smoking policy Responses to anticipated questions and issues that may arise within organisations taking these steps. The resource was reviewed by social and community sector staff as part of its production. It was used in all briefings with SCSOs and was a key part of the standard pack of resources provided in Tackling Tobacco related training. Around 1,300 copies have been distributed to date and it is also available online to download. The feedback has been positive, and organisations have used the resource to revise and update their organisational policies on smoking. 29

30 Casework resources Early in the life of the Tackling Tobacco Program, staff met with Andrew McCallum, CEO of the Association of Childrens Welfare Agencies (ACWA). Andrew noted that addressing smoking was a new area of work for the community sector and that caseworkers are going to have to have some resources in their kitbags. To meet this need, the Tackling Tobacco Program developed two resources to support and engage SCSO workers and assist them to integrate concern about smoking into casework and practice. The resources are outlined below. Breathing Space group cessation resource The Breathing Space: Quit Smoking Program was developed by the Western Sydney Drug and Alcohol Resource Centre (WESDARC) as a group program for smoking cessation. While originally intended for young women, it is suitable for any group of people with an interest in quitting smoking. The Breathing Space resource (Attachment 10) comprises a six-week smoking-cessation program, complete with detailed facilitators notes and all handouts and support material. Breathing Space was promoted through networks and via seminars and conferences, including the joint Network of Alcohol and Drug Agencies and the MHCC Conference. Around 250 copies of the resource have been distributed and demand has been such that it now in a third reprint, funded by the Tackling Tobacco Program. Requests for Breathing Space have come from across NSW and interstate. The entire resource is available for download from at no cost. 30

31 Smoking Care Pack As part of the SCRATC informal audit of existing smoking-cessation resources available to the community sector, the need for a community sector friendly casework tool was identified. In response, the SCRATC group developed the Smoking Care Pack. This resource was modelled on the Indigenous smoking cessation resource, SmokeCheck. The Smoking Care Pack was designed to assist a worker to begin a conversation with a client about smoking, and provide support to quit. The resource comprises a desk tool with prompt questions, a series of four booklets corresponding to different stages of the quit journey, and guidelines on the use of the resource. The resource is available from CCNSW and is also being distributed free as part of any Tackling Tobacco and Smoking Care Training. The resources are available at no cost to community service organisations (see Attachment 11). More than 1800 copies have been distributed. 31

32 Tackling Tobacco website The web presence of the Tackling Tobacco Program is via a specific section of the CCNSW website. Currently this website is being updated, and the Tackling Tobacco pages will be reviewed and revised as part of this process. 32

33 Project development and support Support for social and community service organisations (SCSOs) to implement smoking-care projects has been an important means by which Tackling Tobacco has engaged the sector about tobacco issues. Between 2006 and 2010, the program has supported a variety of smoking-care initiatives, ranging from one-off activities to long-term funding schemes and multiple site projects. This section provides a broad overview of the projects supported through Tackling Tobacco: Community Initiative Scheme (CIS) Peak agency projects: o Breathe Easy Project (MHCC) o Smoking Matters Project (ACWA) Other projects: o Wesley Mission Sadleir Drug Rehabilitation Project o Quit Smoking Support for Young People Project (QSSYP). Community Initiatives Scheme One element of the Tackling Tobacco Program s project development and support was the initiation of a funding scheme the Community Initiatives Scheme (CIS). The scheme encouraged SCSOs to develop multi-component tobacco-control and smoking-cessation initiatives among the disadvantaged groups that they serve. (i) Project aims The scheme offered grants to SCSOs working with highly disadvantaged groups, to expand staff members capacity and skills to provide smoking care; to stimulate integration of tobacco control into policies, programs and practice; and to assist SCSOs to build an internal culture to support tobaccocontrol work. The ultimate aim of this work was to reduce smoking-related harm, primarily among clients, but also among staff and volunteers. (ii) Project grants A total of 20 grants were allocated via two competitive funding rounds. Grant amounts ranged from $4,000 to $30,000. The first grants were promoted in March 2007 through community sector newsletters and networks. In each round, applications were assessed by a panel of CCNSW staff along with representatives from NSW Health and/or the community sector. In the first round of the scheme, 16 applications were received and 10 projects were approved and funded. The total funding granted was $195,270. In the second round, 33 applications were received and 10 projects were funded. The total funding for Round 2 was $189,809. The combined funding for the two rounds of CIS was $385,

34 (iii) Participating organisations The 20 successful CIS projects are listed below in Table 1. This describes the host organisations, the service type of the host program and some of the main project activities. 34

35 Table1 Community Initiative Scheme (CIS) projects Host organisation/program Service type Main project activities CCNSW region Amount (excl. GST) ACON (formerly AIDS Council of NSW) Health promotion organisation Referral resource and network Central and Southern Sydney $20,000 with HIV/AIDS focus developed; targeted social marketing campaign + $5,000 top-up Albury Wodonga Aboriginal Health Service Aboriginal health service Support model; moved from brief intervention to intensive counselling South West $20,000 Benevolent Society Centre for Women s Women s health and wellbeing Quit-smoking support group; Greater Western Sydney $12,650 Health services, including Indigenous support network for Aboriginal women human service workers Calvary Alcohol and Other Drugs Service Drug and alcohol detoxification Smoke-free site policy introduced; South West $18,900 and rehabilitation service nicotine-withdrawal support integrated into program Drug and Alcohol Multicultural Education Drug and alcohol harm Policies reviewed; cessation Greater Western Sydney $30,000 Centre (DAMEC) reduction NGO resources developed; cessation support offered to other services 35

36 Holy Family Social Services, Mt Druitt Health-focused drop-in centre Policy changes; culturally sensitive Greater Western Sydney $20,000 for disadvantaged men cessation-support program for Aboriginal focus clients and staff Independent Community Living Association (ICLA) Long-term supported housing service for people with Smoking-cessation support program Central and Southern Sydney $20,000 psychiatric and other disabilities Leichhardt Women s Community Health Women s health service Brief-intervention protocols Central and Southern Sydney $4,040 Service prioritising women experiencing implemented; smoking-related disadvantage policies revised Mission Australia Housing Long-term supported Individual cessation-support North Sydney and Central $20,000 Accommodation Support Initiative accommodation service for program; case-management Coast people with severe mental protocols updated illness previously sleeping rough Mission Australia Inner City Housing Housing and support initiative Individual cessation-support Central and Southern Sydney $10,000 Program for people living with moderate- program; case-management to high-level psychiatric protocols updated disorders 36

37 Mission Australia Personal Helpers and Recovery program for people Smoking-cessation group support Western $20,000 Mentors Program with severe mental illness programs Mission Australia Triple Care Farm Residential program for young Client and staff quit-smoking Southern $17,483 people with problematic alcohol support programs run; smoking- and drug use related policies revised New Horizons Enterprises Psychosocial rehabilitation Smoke-free policies implemented; Far North Coast $30,000 service for people with mental group cessation-support programs illness who have previously for clients and staff been hospitalised Nowra Family Support Service Support service for Smoke-free policy implemented; Southern $20,000 disadvantaged families cessation-support program offered for clients and staff On Track Community Programs Mental health and disability Smoke-free policy implemented Far North Coast $20,000 accommodation and rehabilitation service Client and staff cessation-support programs conducted Samaritans Social welfare agency for Budgeting resource developed, Hunter $30,000 disadvantaged families, youth, including smoking-cessation 37

38 children and people with information; smoking-cessation disabilities support group Springwood Neighbourhood Centre Community centre program Advocacy to youth services to Greater Western Sydney $20,000 targeting disadvantaged young address tobacco; train-the-trainer women smoking-cessation education sessions Vale Street Centre - Katoomba Social and recreation centre for Two smoking-cessation support Greater Western Sydney $10,914 Neighbourhood Centre people with mental illness groups + $3,000 top-up The Wayside Chapel Support program for people Peer-led cessation-support Central and Southern Sydney $20,000 facing multiple disadvantage, program; smoking-related policy including homelessness changes Youth Solutions Youth drug prevention charity Smoking-cessation education Greater Western Sydney $20,000 resource updated and tested 38

39 (iv) Project findings The evaluation of the scheme used a mixed-methodology approach, which combined quantitative and qualitative data collection. Three data-collection methods were used document analysis, key informant interviews and cross-sectional surveys of staff conducted before and after the implementation of the tobacco policy/smoking-care projects. Overall, findings from the Community Initiatives Scheme support the emerging view that SCSOs can implement programs and policies that contribute to a reduction in smoking-related harms amongst their disadvantaged clientele. With few negative outcomes reported, the 20 projects were largely implemented as planned, with the majority providing smoking-cessation training, integrating cessation support into practice and reviewing their policies on smoking. Qualitative findings indicated that outcomes were very positive for clients who were able to quit smoking or to reduce their smoking greatly. The financial improvements that come with quitting smoking are an important consideration for SCSOs, and worthy of emphasis when providing smoking-cessation support among disadvantaged groups. Notably, the financial benefits for clients often depended on access to free or subsidised nicotine replacement therapy (NRT). Project staff members serving people with severe mental health problems were adamant that subsidised NRT was a necessary part of cessation support for their clients. Both quantitative and qualitative findings reveal positive changes in organisational tobacco policies, and the survey results indicated an important change in attitudes towards smoking with clients as a strategy for building trust. Both reports and surveys indicated significant changes in practice over the course of the project. More staff members reported offering smoking-care support, referrals and free NRT, although there were no significant increases in asking about smoking or recording smoking status. Host organisations reported the development of policies and guidelines, and greater access to free NRT, and that casework tools to address smoking were being provided within their services. In terms of client outcomes, the data obtained from project reports was limited. Overall, the available data shows that around 650 clients and staff actively participated in some form of quit-smoking support. Of these, it is reported that about 160 clients and 20 staff made quit attempts, and that 60 clients and 12 staff stopped smoking during the project. The data have a number of limitations. Data on quitting was by self-report and observation, with no external verification and no set period of abstinence required. There were no control sites and SCSOs were self-selecting. Project reports were written for the funding body, thus introducing potential bias. The cross-sectional nature of the surveys limits the findings to association rather than establishing causality, and also introduces the potential for recall bias among respondents. In using a document analysis to establish qualitative themes, the findings of this study may be limited, due to the interpretation and subjectivity of the reviewers, however much care was taken to ensure accurate and reliable data. Overall, the findings indicated that interested SCSOs can be assisted to improve policies and practice when provided with funding to do so. There may be existing high levels of acknowledgement of the need to address smoking, at least within the Australian context, but less confidence in the idea that clients are 39

40 interested in quitting or capable of quitting. These findings indicate that staff attitudinal barriers are not insurmountable in introducing policy and practice change. (v) Discussion and conclusion The worth of the Community Initiatives Scheme can be considered from a short-term cessation-only perspective or from a longer term and broader organisational change perspective. The project reports that include quit numbers indicate around 60 clients and 12 staff quit smoking. If we judge the scheme only or primarily by the number of people who quit smoking during the projects, then we might conclude that the scheme was a relatively ineffective and expensive undertaking. The project cost nearly $400,000 in direct funding. This figure does not include the in-kind contributions of Cancer Council NSW or the host organisations and their partners. If, however, we assess the scheme according to its broader aims then a more positive and optimistic picture emerges, as is indicated by the following quote: The size of the grants ($30,000) over two projects has achieved systematic in-house training, a shift in policy, a change in attitudes and proficiency among staff, as well as the reduction in tobacco consumption and three quitters. This can be assessed as a good investment (Staff person, Mission Australia). CIS generated 20 smoking-care projects, including in some in the largest community sector organisations in NSW. Over 225 staff members were trained in smoking cessation. Several organisations revised or developed new policy or practice guidelines about smoking that apply to their whole organisation. Most importantly, in terms of the prospects for continued change in the sector, the projects have led to different attitudes and beliefs about smoking. The view that clients are uninterested or unable to quit was soundly challenged. The Be Smoke Free Program has led to a culture of support at The Wayside Chapel, where quitting is on the agenda and all are welcomed and encouraged to participate (Staff person, Wayside Chapel). Where previously the issue of smoking and the harm it imposed upon clients was ignored, the Community Initiatives Scheme has contributed to smoking receiving more attention. The culture and practices around smoking within some participating programs had shifted. Some champions for the cause of addressing smoking emerged and were advocating for further change in their organisations and beyond these are all hopeful signs. On this basis, we can conclude that the Community Initiative Scheme has been a worthwhile investment for Cancer Council NSW. A full report on the Community Initiatives Scheme is available (see Attachment 12). 40

41 Peak agency projects In 2007, the Tackling Tobacco Program initiated a strategy to fund staff positions within peak agencies in the social and community services sector. The aim of these funded positions was to raise awareness of tobacco issues, build capacity to provide smoking cessation-support, and run smoking-cessation support projects with interested member organisations. The two peak agencies identified and funded to recruit a Project Officer position were: 1. The Mental Health Coordinating Council (MHCC) the peak organisation for the non-government community mental health sector in NSW. Its membership is comprised of not- for-profit nongovernment organisations whose activity is wholly or in part, related to the promotion or delivery of services for the wellbeing and recovery of people with mental health problems 2. The Association of Childrens Welfare Agencies (ACWA) the peak organisation for agencies providing out-of-home care and child and family support services in NSW. 1. Mental Health Coordinating Council peak agency project: the Breathe Easy Project The Breathe Easy Project began in February 2008, with the aim of reducing tobacco-related harm in people with mental health problems accessing organisations within the community mental health sector. Smoking cessation has not traditionally been considered a core activity or priority for community mental health organisations, and MHCC recognised that the project would need to encourage a change of culture and reorientation of services to address smoking. A multipronged approach was adopted to counteract the enduring beliefs and assumptions within the mental health sector that have limited its ability to tackle smoking. (i) Project aims The aims of the project were to: Create a better awareness of the need to address smoking to effect changes in smoking behaviour and attitudes Enhance the capacity of the participating organisations to address smoking by changes to organisational policy and practice. More specifically, it was intended that the activities of the project would contribute the following behaviour changes among consumers* and staff of participating organisations: A reduction in the smoking rate among consumers and staff An increase in the percentage of consumers who quit during and by the end of the project An increase in the number of quit attempts by consumers An increase in consumer interest in quitting An increase in consumer confidence in their ability to quit. * Note: The MHCC prefers the term consumers to describe the people who use mental health services. 41

42 (ii) Project components The project time frame was 18 months (October 2008 to June 2009). The project was supported by a part-time (three days per week) Project Officer based at the MHCC. The project utilised a demonstration site model and potential sites were identified via a survey of MHCC member organisations. Successful sites (five of 38 applications) were chosen by a panel of project staff, mental health workers and consumer representatives, and included a range of service types and a geographical spread of services across NSW. Three main strategies were employed at each demonstration site: 1. Training and education for staff (and sometimes consumers) in tobacco cessation and mental health 2. Policy development workshops (i.e. workshops lasting two to three hours, conducted at each site by the Breathe Easy Project Officer) 3. Support for consumers to address their smoking (i.e. 10-week quit-smoking groups based on the SANE Smoke Free Kit, plus subsidised NRT in some sites). Other project activities included a smoking and mental health seminar, and the production of a series of information sheets designed to raise awareness and dispel myths around smoking and mental health (see Attachment 9). These were entitled: Smoking and your mental health Supporting someone with a mental health problem to address their smoking Information for health professionals: smoking and mental health. The evaluation used a combination of consumer and staff surveys, focus groups and participant interviews to assess the effectiveness of the project. (iii) Project findings CONSUMER SURVEYS Consumers were surveyed regarding their smoking behaviour prior to the project commencing (n=83), five months into the project (n=53) and after the project (n=34). Response rates are not available, so findings should be interpreted with some caution. The key findings were that after the project: There was increased client interest in doing something about their smoking (65% to 80%) There was an increase in the proportion of consumers/clients who wanted to quit in the next 30 days (20% to 76%) There was increased consumer confidence to quit smoking (a greater proportion of consumers stated they were extremely or fairly confident to quit than at baseline) There was an increased likelihood of consumers reporting a recent quit attempt (less than three months ago) post-project. 42

43 Other key findings were: The smoking status of consumers was recorded but showed no significant change. The consumer smoking rate was 62.7% at baseline, 73.2% at the interim and 58.8% in the final survey. Almost all consumers were aware of the health risks of smoking. Post-project, 65.5% of consumers did not agree with the view that smoking was helpful for their mental health. Positive aspects of the support group reported by clients were the information, the approach of staff and socialising. Reasons for quitting and barriers to quitting were physical health, finances and family. Barriers to quitting were peer pressure from friend (to keep smoking), the cost of NRT and problems using Champix (varenicline). STAFF SURVEYS Staff and managers at each site were surveyed three times, with 28 staff and managers responding to the baseline survey, 23 participating in the interim survey and 11 respondents completing the final survey. In comparison to staff attitudes reported before the project, key findings were that after the project: Staff reported stronger agreement with the statement that consumers should receive help to address their smoking and that this support should be part of routine care provided by the organisation Staff were also more likely to believe that quitting was not too hard for people with mental health problems Staff were more likely to disagree that quitting smoking would cause a relapse in mental health problems (28% vs. 84%) Staff were more likely to report comprehensive organisational smoking policies were in place Staff were more likely to record the smoking status of consumers, and more consumers were being referred to external supports Staff were increasingly confident in addressing smoking issues with consumers, and in feeling that they had the skills and knowledge to do so. However, some staff members who were smokers reported feeling uncomfortable and hypocritical in raising smoking issues with consumers. Another key finding was that three of the five demonstration-site host organisations reviewed and updated their smoking policies over the period of the project. CONSUMER FOCUS GROUPS One consumer focus group was held at four of the five demonstration sites. A total of 24 consumers participated, of whom nine had recently quit smoking, five were actively trying to quit and the remaining 10 were smokers. The focus groups covered a range of issues: consumers experience of and feelings about smoking, interest in quitting, barriers to quitting, and their experience of the Breathe Easy Project. 43

44 Key findings included: Benefits of smoking: Stress and anxiety relief, respite from boredom, time out and a means of socialising were the main things consumers liked about smoking. Negatives of smoking: These included the impacts on their health and finances, the stigma associated with smoking and the stress of nicotine addiction. Several participants spoke of how the stigma associated with smoking added to those same feelings associated with having a mental health problem. Some participants were also concerned about the impact of smoking on their children and family. Barriers to quitting smoking: Consumers identified these as including having other smokers around them, the stressful circumstances they faced, the lack of affordability of NRT, and the boredom, loneliness and isolation they felt, for which smoking was seen as some respite. Value of attending group sessions: Participants valued the personalised face-to-face support they received (which was additional to what the service normally provided), the opportunity to discuss problems and socialise, and the chance to learn new coping strategies for stresses in their lives. STAFF INTERVIEWS Informal exit interviews were conducted with staff at four of the five sites, to identify barriers to working with consumers on smoking, pros and cons of the project, impressions of the group program, and what other supports would be useful to address smoking. Key findings included: Barriers to supporting clients to quit: Issues identified were lack of time, smoking not previously a priority, staff attitudes that smoking is normal activity among consumers, lack of organisational policy on smoking, and lack of guidance and ways to proceed on the issue. Project benefits: Projects provided insight into how consumers really felt about their smoking, and challenged the view that smokers were uninterested in quitting; increased self-esteem and selfconfidence among consumers were also mentioned as benefits. Quit group benefits for consumers: Benefits included the opportunity for peer support, social contact, honest sharing and the development of friendships. Benefits of free or low-cost NRT for consumers: This allowed consumers to try different NRT products to see which suited them best. Overall, staff felt that their participation in the program was worthwhile and added a new dimension to their support for consumers. Once our ideas had been challenged, we just felt: How could you not do it? (Staff person at one site) The programs have also prompted some staff to quit smoking. 44

45 (iv) Discussion and conclusions The experience of the Breathe Easy Project is indicative of a changing culture around smoking within the community mental health sector. A number of results from the project underscore the need for that change. The Breathe Easy Project found that: Consumers can and want to do something about their smoking: The view that people with mental health problems are uninterested in quitting was challenged. Consumers were very open to participating in quit support and found that it provided benefits to them beyond smoking cessation. At the same time, flexibility is required: many consumers want to cut down their smoking initially rather than giving up straight away. Quitting for some people with mental illness may take place over an extended period. Staff and organisations also benefit from addressing smoking: The projects contributed to a change in staff attitudes to smoking and they saw the benefits that quit support provided consumers. Offering support provides another dimension of care for services. Providing such support may assist staff members who smoke, to quit. Leadership is important: Managers and key staff at each site were instrumental in making things happen. At the same time, other consumers and staff were consulted and given the opportunity to discuss the project. The Breathe Easy Project provides an illustration of an organisational change approach to addressing smoking. The combination of training and education for staff, reflecting on and revising organisational policy, and providing direct cessation support to consumers can all contribute to changes in culture and practice regarding smoking. For a fuller discussion of the Breathe Easy Project, including project recommendations, see Breathe Easy: lifting the burden of smoking. Final Project Report July (Attachment13). 2. Association of Childrens Welfare Agencies peak agency project: the Smoking Matters Project In March 2008, a partnership project between CCNSW and the Association of Childrens Welfare Agencies (ACWA) was initiated to raise awareness of the need to address tobacco among ACWA s 100 member organisations. The project sought to lift the burden of tobacco use on low-income and disadvantaged groups by working with community organisations that are members of ACWA. (i) Project aims The 12-month pilot project, entitled Smoking Matters, aimed to: Encourage new policies and practices around smoking within member organisations Increase the capacity of staff to address smoking with clients through training and development of casework tools and resources Stimulate and support specific tobacco-control and smoking-cessation projects. 45

46 (ii) Project components The project aims were addressed by developing a workshop available to the whole ACWA membership, as well as providing online information and resources. In addition to these broad strategies, member organisations were invited to apply to become demonstration sits for the Smoking Matters Project. Successful organisations received a more intensive intervention, supported by the Smoking Matters Project Officer. After a sector survey administered in October 2007, six demonstration sites were selected from 17 that had expressed an interest. The sites were able to tailor the smoking-care intervention according to their needs, by choosing from a menu of activities presented by the Project Officer. It was hoped this approach would encourage active commitment to the project. One organisation chose to focus its attention exclusively on producing a web-based information resource on smoking; the others selected a range of activities. TRAINING WORKSHOPS Part of the Smoking Matters Project was to design, develop and deliver two workshops through ACWA s training arm, the Centre for Community Welfare Training (CCWT). The two workshops were each scheduled to run twice during the year. The Smoking Matters workshop covered the broad issues of tobacco use, looking at the social justice context of smoking and disadvantage, and how community service organisations could respond. The Lifting the Burden workshop focused on therapeutic interventions used to treat tobacco addiction, such as brief intervention and NRT, relapse prevention, and the role of organisational policies and procedures to de-normalise smoking in service environments. Each participant received a workbook with a copy of the activities, PowerPoint slides, references and useful websites. They were also given a copy of CCNSW s policy toolkit and NSW Health s brief intervention resource Let s Take a Moment: quit smoking brief intervention a guide for all health professionals. COMMUNICATION STRATEGIES The aim of the communication strategy was to disseminate information, raise awareness and increase knowledge about the Smoking Matters Project and the wider Tackling Tobacco Program. The target audience was ACWA members and the broader community sector. A Smoking Matters website was developed, which contained information on training and the demonstration sites, and links to other information and resources. Other strategies included writing articles for the ACWA newsletter, promotion through the ACWA training calendar (which had a distribution of 17,000) and a poster presentation at the ACWA conference. 46

47 CALENDAR WORKSHOPS The two calendar workshops were each held twice during the year as scheduled. A total of 30 participants attended the workshops, with positive feedback received about both days. Some participants in the Smoking Matters workshop expected more concrete strategies on dealing with tobacco use. It was explained that this material was covered in the second workshop, called Lifting the Burden. The training developed during the Smoking Matters Project and the associated exercises, handouts and other resources became the basis for all smoking-care training that has been offered subsequently through the Tackling Tobacco Program. A familiarisation workshop was held in February 2009 to enable the training and resources to be shared with other potential trainers who could deliver the material. The purpose of this was to grow the capacity of the social and community services sector to offer smokingcare training, a need that had been identified by CCNSW. DEMONSTRATION SITES The six demonstration sites were able to tailor the smoking-care intervention according to their needs, by choosing from a menu of activities presented by the Project Officer. Table 2 describes the demonstration sites and the main activities they undertook. All but one demonstration site participated in training. Macarthur Diversity Services (MDS) did not include training; they decided to conduct a quit group and also a resource, translated into Arabic, which outlined some of the main contents of cigarette smoke. This resource was produced as a flash animation, and also as a flyer and poster. Two versions, in Arabic and English, were produced.the resources was used by MDS and also shared with other demonstration sites. MDS had also distributed the resources through their service networks and presented them at interagency meetings. They are also available on the MDS website at 47

48 Table 2 Description of demonstration sites in Smoking Matters Project Organisation Target group Services provided Main project activities Allawah House Females aged years who are 24-hour supported Staff training; develop written resources on smoking; arts and homeless or at risk of homelessness accommodation; independent information workshop on smoking; review smoking policies housing Macarthur Diversity Marginalised children, youth and Settlement and community Develop flash animation and print resources on cigarette Services families living in the Macarthur services for refugee and contents; quit-smoking group region migrant groups The Burdekin Young people aged years Range of integrated Staff training; have staff use casework tools and resources within Association and their families accommodation, care and case management; education session on smoking for clients support services UnitingCare Young people aged years at One-to-one casework; Staff training; have staff use casework tools and resources within Burnside- Macarthur risk of disengaging from school or assistance with case management; run information sessions on smoking within Youth Services homelessness accommodation; counselling program and links to education and employment Youth Care UPA Children and youth aged 0 17 years Medium- to long-term Staff training; review smoking policy and procedures; include unable to live at home accommodation; casework; smoking-cessation strategies in staff training/induction; provide 48

49 high-intensity foster care support to clients, staff and carers to quit smoking Child Adolescent Young persons aged 8 24 years Residential care; intensive Staff training; review smoking policy and procedures; include Specialist Programs who have suffered abuse and support mentoring; learning smoking-cessation strategies in staff training/induction; provide and Accommodation cannot live at home support and semi- support to clients, staff and carers to quit smoking (CASPA) independent living 49

50 The training at the other five demonstration sites was conducted by the Project Officer, and ranged from half- to full-day sessions to multiple sessions lasting two to three hours on different days. While training content was able to be negotiated according to each demonstration sites preferences, the content chosen was largely similar. The main topics are listed in the box below. Table 3 Topics covered in staff training across five demonstration sites Links between smoking and disadvantage Health effects of smoking Benefits of quitting Nicotine addiction Providing interventions Motivational interviewing 5As brief-intervention framework Withdrawal symptoms Coping with cravings Introduction to the Smoking Matters resource toolkit (iii) Project findings Results from the pre-, post- and follow-up surveys of these demonstrations sites together with other findings, were as follows. 50

51 Training Component Response rate: The response rate for the surveys before and after the training sessions was almost 100%, with 63 of the 64 participants providing post-training surveys. The response rate of the threemonth follow-up survey was approximately 50%, with 34 respondents. Confidence measures: As shown in Figure 2 (below), confidence in raising the issue of smoking cessation with clients, helping them to quit, and providing an appropriate referral increased significantly after the training session and remained significantly higher than baseline levels at the three-month followup survey. Confidence in informing clients of the risks of smoking also increased significantly post-training from 94% to 100% and remained at this level after three months. However, the difference at three months compared to baseline was not statistically significant due to the lower response rate. Confidence in telling people about the benefits of quitting was already high (99%) prior to training, therefore no significant differences were observed. Training outcomes: Smoking Matters Project Note: significant increase post training or at three-month follow-up compared to the pretraining survey indicated by * (p<0.05) and ** (p<0.01), and significant decrease indicated by +. 51