Telehealth: a new opportunity to discuss smoking cessation with indigenous cancer patients and their families.

Abstract

Public health initiatives aimed at promoting the negative health impacts of smoking have led to decreases in smoking among non-indigenous populations; however, higher rates of smoking continue to be the leading cause of disease burden among indigenous populations throughout the developed world 1. For Aboriginal and Torres Strait Islander peoples (hereafter referred to as Indigenous Australians), the situation is dire with Indigenous Australians 1.9 times more likely to die of lung cancer Rates of smoking vary within and between Indigenous communities with significantly higher rates reported for Indigenous populations (41%) compared with non-Indigenous Australians (16%) 2. Remoteness and younger age appear to be critical risk factors for higher rates of smoking among Indigenous Australians with rates as high as 62% reported for women aged 15 to 34 years in a remote community in North Queensland 3 and 76% among men in a community in the Northern Territory 4. Currently, little is known regarding the best approaches for reducing smoking rates among Indigenous people Mainstream approaches involving public policy initiatives (increasing taxes, plain packaging and smoke-free venues) appear to have had little impact on smoking rates among Indigenous Australians. Other interventions directed at Indigenous Australians have had little impact and/or the quality of evaluations have been poor (e.g. small sample sizes, lack of inclusion of smoking cessation measures) 5. In this paper, we describe our efforts to embed a prevention model to facilitate education about the links between smoking and lung cancer within a clinical consultation utilizing a teleoncology model. Importantly, within this model, we specifically address cultural and social determinants (e.g. normalization of smoking, family influences) that have been linked with higher rates of smoking in Indigenous populations. We believe that urgent attention is needed in order to develop tailored, community-based, prevention programmes that target key psychosocial determinants identified as underpinning the high rates of smoking observed in Indigenous communities. We argue that clinicians can play a leading role in implementing these interventions during usual consultations when conveying information to patients and families regarding a cancer diagnosis and treatment. In this paper, we describe (a) the teleoncology model implemented at The Townsville Cancer Centre (TCC) in North Queensland, (b) a case study involving the delivery of education concerning smoking and lung cancer; and, (c) the components of the My-Family oriented Anti-Tobacco Education (My-FATE) Model. Rates of smoking are higher among remote Indigenous communities, yet people living in rural and remote communities have limited access to public health and preventative services, including smoking education and cessation programmes. New models based on telehealth, which were initially developed to improve access to specialist treatment in rural and remote areas of Australia, have the potential to bridge the gap between people living in rural and remote communities and the provision of preventative health services 6. To extend services to people living in rural and remote communities, a teleoncology model of cancer care has been established within The Townsville Cancer Centre (TCC) in North Queensland, Australia 7. In this model, patients can access some of their specialist services closer to home in rural and remote communities. Evaluations of this model conducted with Indigenous and non-Indigenous patients have reported high satisfaction rates 8, 9. Health professionals welcomed this model of care for many reasons including the ability to readily connect with specialists, broaden their scope of practice and provide continuity of care 8. One of the advantages of this model is that more family members can attend the consultation closer to home. At teleoncology consultations involving Indigenous patients, many family members accompany patients whereas at face-to-face consultations in larger centres, only one escort may accompany the patient. This telehealth setting provides an ideal opportunity to embark on discussing matters related to prevention and smoking cessation with patients as well as family members. The following case study describes and illustrates how a teleoncology consultation was used with a focus on smoking prevention and cessation. A 56-year-old Indigenous man from a remote community in North Queensland, more than 800 km from TCC, was seen by his oncologist via telehealth for his incurable and metastatic lung cancer. He was on an oral chemotherapy agent to improve his quality of life. He was accompanied by an Aboriginal Health Worker and ten of his family members. More than half of these family members were current smokers. At the end of the discussions regarding prognosis and treatment, two younger family members asked the oncologist what had caused their uncle's lung cancer. The oncologist linked the lung cancer with the patient's smoking history. He showed the family members the CT scan images using screen sharing to display the location of the cancer and to explain how carcinogenic agents in smoke travel to the lungs through the airways. Family members then engaged in a discussion amongst themselves, the Aboriginal Health Worker and the oncologist regarding the carcinogenic nature of smoke and why they should consider quitting. A major obstacle to the family members' quitting smoking has been that apart from the services of a doctor, there was no coordinated anti-tobacco programme in that community to mentor monitor and facilitate quitting. As the result of gaining these insights, a multi-disciplinary team of health professionals from The Townsville Hospital and Health Service and James Cook University developed an innovative, culturally appropriate, family-oriented model of anti-tobacco programme for rural and remote Indigenous communities. This model is described below. My-FATE is a novel, family-centred model which engages and motivates Indigenous family members to review their smoking status 10. In this model, the treating medical specialist of a patient diagnosed with a smoking-related health condition plays a major role in the delivery of anti-tobacco education to the patient's family members through videoconferencing, assisted by a local Aboriginal community worker and rural based generalist doctors. My-FATE uses culturally appropriate education materials designed by and for Aboriginal and Torres Strait Islander Australians, as well as the patient's X-rays and scans to explain the impact of smoking on the patient's condition. In addition to the brief intervention, referrals to the QUIT helpline and the local Alcohol, Tobacco and Other Drugs (ATODS) service are given. Family members with a nicotine dependence and ready to quit smoking are offered Nicotine Replacement Therapy (NRT) by the rural-based doctors. We are currently working on developing methods for allowing the ongoing refinement of the My-FATE model. This will involve consultation with Indigenous community members, as well as others involved in the delivery of cancer care. A key challenge is to encourage health professionals and medical specialists to take part in the My-FATE model in a consistent and sustainable manner. While we acknowledge that further evidence is needed to determine which interventions are most effective for reducing rates of smoking among Indigenous Australians, we hope that our description of our approach will encourage other clinicians to consider incorporating efforts to address psychosocial determinants important in facilitating education and prevention of smoking-related illnesses, including lung cancer.