Seham Girgis, Maria-Jose Velasco, Nicholas Zwar, Jeanette Ward

1. Smoking Cessation for Arabic-speakers Study (SmoCAS):A Randomised Trial of a GP-initiated tobacco control intervention Seham Girgis, Maria-Jose Velasco, Nicholas Zwar, Jeanette Ward Centre for Research, Evidence Management and Surveillance (REMS),SSWAHS

3. Acknowledgment This study was supported by a NHMRC Project Grant 295000.

4. Introduction • In Australia, almost one in four adults (23%) smoked in 2004-05 (ABS 2006). • Some ethnic groups have higher rates of smoking than the Anglo-Celtic ethnic majority. • For example, higher rates of smoking were found among: • Lebanese-born men (41.7%) • Vietnamese-born men (30.0%) • Lebanese-born women (29.2%)

5. Introduction cont. • Cigarettes smoking and narghile smoking are entrenched in the Arabic culture. • About Ethnic minority groups: • Robust epidemiological data are largely lacking. • Barriers to smoking cessation are poorly understood. • Are less likely to have access to culturally appropriate preventive care in their adopted countries. • Are excluded from behavioural research because of language and cultural differences. • Are excluded from behavioural research because of language and cultural differences.

6. Introduction cont. • Smoking cessation interventions have focused on majority populations who speak English. • There has been increasing interest in generating a more rigorous evidence base for the effectiveness of interventions specifically designed for particular ethnic or racial groups.

7. In absence of evidence !! • (Fiore et al 2000, US Clinical Practice Guideline: Treating Tobacco Use and Dependence) stats that “members of racial and ethnic minorities should be provided treatments shown to be effective in this guidelines” • A systematic review of 58 studies concluded that proactive telephone counselling involving multiple contacts significantly increased abstinence rates (OR 1.2, 95%CI 1.1, 1.4).

8. Aims • To evaluate the effectiveness of a culturally specific and intensive smoking cessation intervention initiated but not delivered by GPs to increase point prevalence of abstinence at six and twelve months • To determine the acceptability of this cessation intervention.

9. Methods • Design Randomised Controlled Trial • Setting Practices of 34 GPs in Sydney South West • Subjects Four Hundreds and seven patients aged 18-65 years from Arabic background identifying themselves ascurrent smokers.

10. GP recruitment • 101 Arabic-speaking GPs in SSW • 49 Eligible GPs • Work more than 24 hours/ week • At least 30% of patients were Arabic • 34 (69%) consent, 6 withdraw • 28 GPs participated

11. Patient recruitment • Inclusion criteria • age 18-65 years • Arabic Background • Waiting room questionnaire • Socio-demographic data • Smoking history • Nicotine dependency (Fagerstrom test) • Stage-of-change • Attitudes and beliefs towards smoking (A-RSSQ) (Haddad 2001)

12. Randomisation • Eligible smokers were randomly assigned to either : • Their GP’s ‘usual care’ for smokers (Control). OR • Culturally specific and intensive telephone-based program delivered by a bilingual psychologists (Intervention).

13. Intervention Smokers randomised to Intervention received: • Six proactive telephone counseling sessions based on the 5 As approach (ask, assess, advice, assist, arrange follow-up): • Call 1: assessment call • Call 2: quit date • Call 3: one week after the quit date • Calls 4, 5, 6: three weeks, six weeks and 12 weeks after the quit date. • Self-help material and written information (Arabic and English). • News-letter (Arabic and English)

14. Outcome measure At 6-month and 12-month follow-up: • Self-reported abstinence (point prevalence abstinence). Data analysis • Intention to treat principles were adhered to for all analyses

15. RESULTS

16. Patients recruitment flow chart 3146 Patients approached Ineligible (n=1212) Refusal (n= 497) Smokers (n=194) Smokers (n=213) 101 (47%) Consented 112 (53%) Declined Lost to 6-month follow up (n=41) Analysed (n=153, 79%) Lost to 6-month follow up (n=51) Analysed (n=162, 76%) Lost to 12-month follow up (n=66) Analysed (n=128, 66%) Lost to 12-month follow up (n=95) Analysed (n=118, 55%)

17. Baseline demographic characteristics of participants

18. Baseline demographic characteristics of participants

19. Baseline smoking pattern

20. Nicotine dependency (Fagerstrom test)

21. Stage-of-Change

22. Behavioural change at 6 and 12 months

23. Acceptance of referral • Less than half of smokers assigned to Intervention (n=101, 47%) gave consent to their GP to be referred to telephone counselling. • Smokers assigned to intervention who declined telephone counselling were significantly more likely than those who consented to be in an advanced stage-of-change (χ2=9.2, df=2, P=0.01).

24. Number of patients who completed telephone smoking cessation intervention calls

25. Characteristics of intervention group participants by willingness to be contacted by a counsellor

26. Comparisons of smokers assigned to intervention

27. Telephone counseling rating

28. Respondents views about telephone counseling

29. Conclusion • Stage-of-change was significantly associated with initial uptake of GPs’ referral to telephone counselling. • Arabic speaking smokers in this study did not agree to proactive telephone counselling for smoking cessation.

30. Where TO From Here?

31. This study highlights: Strategies with proven effectiveness among general population is not necessary applicable for sub-groups such as ethnic minorities. The need of further well designed trials of evidence based strategies among Arabic smokers. The need to understand better the characteristics of Arabic smokers willing to accept smoking cessation and the circumstances in which this might occur.

32. THANK YOU

33. Knowledge and attitudes towards smoking

34. Beliefs

35. Strategies when attempting to quit smoking

36. Motivation

37. 0-2 very low dep • 3-4 low • 5 medium • 6-7 high • 8-10 very high

38. Smoking pattern