Almost half of pregnant Indigenous women smoke compared to one in eight in the non-Indigenous population. This means 7,000-9,000 Indigenous Australian babies every year are exposed to smoking in the womb.
Children exposed to tobacco smoke before birth are at increased risk of “glue ear”, which causes hearing loss, learning problems and behavioural problems. They are also at greater risk of asthma and bronchiolitis in childhood, and chronic lung disease in adulthood.
Children born to mothers who smoke are more likely to become smokers. Some try smoking as young as five years old.
We have identified three key areas that need urgent remediation if Indigenous women are to be effectively supported to quit:
subsidised access to oral forms of nicotine replacement therapy
clinician training to better manage smoking during pregnancy
health promotion messages to address the challenges Indigenous women face when quitting.
Access to nicotine replacement therapy
Australian GP guidelines recommend if a woman cannot quit smoking during pregnancy or when breastfeeding, she should be offered oral forms of nicotine replacement therapy (NRT), such as inhalers or lozenges. These are faster-acting than nicotine patches and should be considered the first-line treatment.Ray Kelly
Patches are listed on the Pharmaceutical Benefit Scheme (PBS), but oral NRT (inhalers, lozenges, gum and nicotine spray) is not listed or subsidised. These options are expensive when bought in retail outlets. A full, 12-week course costs around A$500 for the nicotine spray or lozenges, and A$800 for the inhaler.
For the past three years, I have lobbied the government and pharmaceutical companies to remediate this. Because patches are already listed, putting oral NRT on the PBS would involve only a minor change to add extra products to the listing.
But while the government may be willing, the pharmaceutical companies are reluctant to repackage these products for prescription use. My investigations reveal pricing is a key factor: the government is unlikely to pay as much for PBS-listed products as pharmaceutical companies expect.
PBS representatives stepped in to do their own negotiations with pharmaceutical companies, but these appear to be gridlocked.
Health professional training
We recently surveyed 378 Australian GPs and obstetricians and found few are confident to prescribe NRT to pregnant women. Of the respondents:
88% said NRT was safer than smoking
66% considered NRT moderately to highly effective
11% always prescribed NRT to a pregnant smoker
63% agreed management would improve if oral NRT was on the PBS
78% agreed further training was required.
In another study, some health workers did not consider it worthwhile to offer quit advice to Indigenous pregnant women, due to low success rates.
To overcome these barriers, we are developing a webinar intervention with six Aboriginal Community Controlled Health Services on how to manage smoking during pregnancy. The Indigenous Counselling and Nicotine (ICAN) Quit in Pregnancy program will use an ABCD approach:
brief advice to quit
cessation (quit) methods (nicotine replacement therapies, which will be provided at no charge)
discuss the psychological and social context of smoking.
“D” is crucial to understanding and effectively supporting a pregnant Indigenous smoker to quit. The intervention will be trialled in three to four states. If successful, it can be easily scaled up nation-wide.
New health promotion messages
A wealth of evidence has amassed in the past five years to better inform messages around Indigenous women smoking during pregnancy. It’s time to translate this knowledge into practice.
Many Indigenous women face difficult life circumstances, coupled with social norms of smoking. Health promotion programs and messages must account for these circumstances and focus on key messages. These include:
increasing the visibility of harm for babies
addressing the importance of quitting rather than just “cutting down” – making quitting seem worth it
reassuring that stress will decrease once nicotine withdrawal is controlled
offering high-quality support – women need to know they are not alone and can be helped.
Health promotion programs should be delivered to women through targeted print and film media, and during the consultation at primary care services.
Indigenous women must have an opportunity to address their smoking when pregnant. They need to be supported by making essential medications easily available and affordable, building capacity by training health professionals, and getting a broad reach for the right messages to this high-priority group. This way we can start to move forward and close the gap in this area.
Gillian Sandra Gould receives funding from NHMRC, CINSW, Hunter Cancer Research Alliance, University of Newcastle, Royal Australian College of General Practitioners (RACGP) Foundation, Ministry of Health NSW, John Hunter Hospital Charitable Foundation. She is affiliated with the Australian Association of Smoking Cessation Professionals, the RACGP, the Australian Medical Acupuncture College, and Australasian Society for Behavioural Health and Medicine.
Authors: Gillian Sandra Gould, NHMRC Research Fellow and CINSW Research Fellow, Centre for Brain and Mental Health Research, University of Newcastle