Author's response to reviews

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1 Author's response to reviews Title: 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 Authors: Jamie Bryant (Jamie.bryant@newcastle.edu.au) Billie Bonevski (billie.bonevski@newcastle.edu.au) Christine Paul (Chris.Paul@newcastle.edu.au) Version: 2 Date: 4 October 2011 Author's response to reviews: see over

2 Dr Linda L Pederson Journal Editorial Office BioMed Central Sunday, 2 nd October, 2011 Dear Dr. Penderson, Thank you for your dated 1 st October 2011 and the opportunity to revise and resubmit our manuscript (MS: ) entitled A survey of smoking prevalence and interest in quitting among social and community service organisation clients: a unique opportunity for reaching the highly disadvantaged. Please find below our detailed responses to the reviewers suggestions. We have attempted to make all changes suggested where appropriate and provide explanations where we felt a change was not appropriate or possible. Reviewer One: 1. The title should include Australia as the location for the research The location of the study has been added to the title of the manuscript. 2. Abstract- The abstract should include a brief description of what a SCSO is for people who do not know. A brief description of what a social and community service organisation is has been added to the abstract (see page 2). 3. Abstract- The total number of clients approached should be added The total number of clients approached has been added to the abstract (see page 2). 4. Abstract- In the results it is not clear how occasional smoking is defined We have revised this section of the abstract to provide daily smoking and occasional smoking rates separately to ensure clarity. We have also added a definition of occasional smoking. See the results section of the abstract on page Abstract- The % provided for those who had made an average of two quit attempts is not given. The number of quit attempts was collected as a continuous variable and the mean and standard deviation for the number of quit attempts made by participants is given. The % is therefore not required.

3 6. Abstract- The data for the general population of smokers in Australia should be added and the word significantly removed from the comparisons if statistical tests were not done. The word substantially could be used instead. The smoking prevalence of the general population (15.1%) has been added to the abstract. Please note that we have also taken this opportunity to update the general population Australian smoking rate reported in the discussion (page 9) in light of data that has been released since the original submission. The word significantly has been replaced with substantially as suggested. 7. Abstract- The conclusion seems to go beyond the data We have removed the final sentence of the conclusion to address this comment. 8. Introduction the 2020 target for smoking prevalence is not given. The 2020 target for smoking prevalence is given in the first sentence of the first paragraph- In 2009, the National Preventive Taskforce recommended that daily smoking prevalence in Australia be reduced to less than 10% by Introduction- What is the difference between disadvantaged smokers and highly disadvantaged smokers? The reference to highly disadvantaged smokers in both the title of the manuscript and the introduction has been revised to disadvantaged smokers. 10. Introduction- There are some references provided (9-12) with no information given about what was found in these studies. We have elaborated this section to provide details about the evidence provided by the three studies cited (see page 4). 11. Methods I think that the use of a touch screen interview is a great idea. Were the data collected anonymously or confidentially? The data was collected both anonymously and confidentially. This has been added in the methods section on page Methods How were the sites selected? The organisation was selected based on existing research partnerships. Once consent was obtained from the Chief Executive Officer to participate in this research, a top down approach to recruitment was used, with managers of services contacted and their willingness to be involved in the research confirmed. This has been added to the methods section of the manuscript (see page 4).

4 13. Methods What are the definitions of distressed or ill and how was this determined? Participants attended an appointment seeking financial and/or material assistance prior to being invited to complete the survey. If the caseworker judged the participant to be distressed or ill- such that they did not think they could complete the survey- the client was not invited to participate. This has been added to the explanation of eligibility criteria (page 4). 14. Methods What is an emergency relief interview? Participants were individuals who were attending the service to seek financial or material assistance- for example food vouchers, grocery items, assistance with paying bills or purchasing medications. The wording in the paragraph titled Recruitment and procedure has been changed to reflect what is described in the preceding paragraph. See page Methods What is the definition of occasional smoking exactly once a week, less than once a week? Participants were asked to indicate whether they i) smoked daily, ii) smoked at least once per week, iii) smoked, but less often than once per week, or iv) were non-smokers (see page 5). Occasional smokers are defined as those who are not daily smokers and reported to be occasional smokers both at least once a week and less than once a week. We have separated our reporting of daily and occasional smokers to clarify this in the abstract and results. We have also defined occasional smokers as non-daily smokers in the abstract. 16. Methods What was done with people who were occasional smokers with regard to the question about age started to smoke daily? Only those who reported smoking daily were asked what age they started smoking daily. This has been amended in the methods section (page 4/5). 17. Results the means for ages for participants and nons should be given. This has been added to the first paragraph of the results (see page 5). 18. Results Information on the % of individuals who made 2 or more quit attempts should be given, along with a range of numbers of quit attempts. The mean and standard deviation for the number of quit attempts made by participants is given, and we have added the range. The % is therefore not required.

5 19. Results In the section on receiving help from the SCSO, it is not clear what group the 52.8% is referring to. Current smokers were asked whether they would be interested in receiving support to quit smoking from organisation staff (yes/no). This is described in the methods section. The 52.8% is referring to the proportion of participants who answered yes to this question. 20. Discussion it is not surprising that individuals in this group have not used NRT given the cost issues; this fact could be mentioned. We thank the reviewer for the suggestion. We have added the barrier of cost of NRT as a potential explanation for non-use in the discussion (see page 10). 21. Discussion- In my opinion it would be interesting to follow up this research with some qualitative interviews particularly with reference to the use of quit lines. I looked for such a suggestion in the discussion. We have added this suggestion to the discussion (see page 10). 22. Discussion- The final recommendation about the SCSO involvement is interesting, but unless there is some data available on effectiveness of such interventions, it is not warranted. We do not yet have evidence of the effectiveness of such interventions, however a large randomised controlled trial is currently underway to answer this question. The following sentence has been added to the final paragraph of the discussion to clarify this point- 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[9]. Reviewer 2 1. Intro middle of first paragraph. I believe the authors mean overstated rather than understated. Thank you. This has been corrected. 2. Are there barriers to SCSO intervention such as limited staff interest or competing priorities? Barriers to intervening in the SCSO include lack of staff time and training, competing priorities and insufficient resources. These are reported in a separated paper exploring the acceptability of the SCSO as a setting for targeting disadvantaged smokers and has been cited in the introduction (page 3, reference 9).

6 3. Might note in Table 1 that ATSI refers to Aboriginal and Torres Strait Islander. Also might insert ATSI in parentheses after Aboriginal and Torres Strait islander under measures #1. We have expanded ATSI to Aboriginal or Torres Strait Islander in table 1. The abbreviation ATSI is no longer used in any part of the manuscript. 4. Under smoking behaviors first line indicates over two thirds (61.4%) reported daily or occasional smoking." However, this is less than two thirds. Thank you. This has been corrected to almost two thirds. 5. It might be helpful in future research to know more about why respondents were less interested in support from Quitlines. Are cash rewards a viable option? We have suggested that future research to explore reasons why disadvantaged smokers seem to be less interested in using available services, such as Quitline (see page 10). 6. May be important to better understand barriers to use of evidence based services for those accessing SCSOs. We agree. This has been added as a suggestion for future research in the discussion (see page 10). 7. Although just over half of participants reported that they would like help from community service staff to quit smoking, it is likely that actual utilization of help if offered would be considerably less. We agree with the reviewer s statement. The following sentence has been added to the final paragraph of the discussion- 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.

Name: CQ4 DP1 What actions are needed to address Australia s health priorities?

Name: CQ4 DP1 What actions are needed to address Australia s health priorities? health promotion based on the five action areas of the Ottawa Charter levels of responsibility for health promotion the benefits