A monitoring and site visit intervention to reduce sales to minors at packaged liquor outlets.

ISSUE ADDRESSED: Selling alcohol to a minor is a serious offence in the New South Wales Liquor Act. However, minors report they can purchase alcohol easily. This study used an intersectoral partnership between the Central Coast Local Health District (CCLHD) Health Promotion Service, and Liquor & Gaming NSW (L&GNSW) Compliance Operations to test a site visit intervention to increase ID checks at packaged liquor outlets (PLOs). METHODS: As the current legislative framework does not allow minors to attempt to purchase alcohol from PLOs, even under compliance operations, this study employed pseudo-minors aged 18-19 years. Pseudo-minors visited all PLOs on the Central Coast, NSW in four survey rounds, attempting to purchase alcohol without ID. If a PLO sold alcohol to the pseudo-minor, they received a visit from a Health Promotion Officer and L&GNSW Inspector to inform them of the sale and that they are at risk of selling alcohol to a minor. RESULTS: Site visits were an effective intervention to increase the rates of ID checking. Alcohol sales to pseudo-minors without ID decreased from 34% in Round 1 to 7% in Round 4. Young sales staff and independent stores were less likely to check ID. CONCLUSIONS: This intervention was associated with some of the lowest rates of underage alcohol purchasing reported to date. However, it may not be sustainable in the long term. It is recommended that: future studies randomise site visits to investigate their contribution to the observed reduction, cost effectiveness of the intervention is explored and legislative change to allow controlled purchase operations for alcohol is considered. SO WHAT?: Young people under 18 years of age should not be able to purchase alcohol from liquor licence outlets, and strong laws apply if a sale is detected. However, despite these rules, young people still report they can access alcohol in this manner. Whilst our intervention of site visits with the regulatory body saw decreases in sales to our pseudo-minors, we advocate for controlled purchase operations (similar to tobacco control) as a more sustainable and effective intervention to reduce sales to minors - while this is not yet legislated for packaged liquor outlets in Australia, it is deemed best practice in other countries.

Assessing the responses of smokers to requests to stop smoking on hospital grounds.

ISSUE ADDRESSED: Fear of aggression is often cited as an issue for health service staff in approaching smokers who are breaching smoke-free policies. This study collected data to quantify the interactions between Health Promotion Service staff and smokers. The aim was to trial de-escalation based protocols for Authorised Inspectors and one for general staff with regards to the aggression risk to staff when approaching smokers within hospital grounds. METHODS: The study design was a non-randomised trial with no control group. A standard protocol was developed, based on de-escalation techniques. The primary outcomes of the study were measures of aggression and smokers' compliance with instructions to extinguish their cigarette. Aggression was recorded using the Modified Overt Aggression Scale (MOAS). Two hundred interactions were conducted with smokers during business hours by Health Promotion Service staff. The first 100 interactions were based on an enforcement methodology typically delivered by Authorised Inspectors, while the second 100 interactions were based on an information and assistance methodology to reflect those that could be delivered by general health service staff. RESULTS: Only four instances of aggression were experienced, representing 2% of all interactions. Each of these was limited to verbal aggression. No self-aggression, aggression against property, or physical aggression was encountered. Smokers were significantly more compliant to instructions to extinguish their cigarette in the enforcement method (64%) than the information and assistance method (45%) (P < .001). Groups of smokers were more compliant than individual smokers in the enforcement method (76.3% compared to 56.5%, P < .05). CONCLUSIONS: This study quantifies the risk of aggression to health service staff conducting smoking compliance interactions using two methodologies. By following de-escalation-based protocols, staff can approach smokers in a low-risk manner and support smoke-free policy implementation and compliance. For general staff, the emphasis of interactions must be on providing information and assistance to smokers, not enforcement, as indicated by the reduced rate of immediate compliance, introducing an increased risk of escalation if enforcement is attempted. SO WHAT?: These protocols could be implemented by other health services or organisations that are seeking to optimise the involvement of staff in supporting smoke-free policies.

Exploring and reorienting psychiatrists' attitudes regarding smoking cessation and its potential to improve mental health outcomes: a pilot study.

OBJECTIVE: The aims of this study were to explore the knowledge, attitudes, confidence and practices of Australian psychiatrists and psychiatry registrars with regard to smoking cessation with their patients and to promote clinical practice reflection and re-framing. METHODS: A mixed-methods questionnaire was developed. Interviews were conducted via telephone or face-to-face utilising participatory action research principles. Qualitative data were de-identified and analysed following a reflexive thematic approach. RESULTS: The questionnaire was completed with 15 participants. The majority worked in the public health sector and agreed that smoking cessation could be used as a clinical tool across mental health services. However, nearly all of the participants reported being unfamiliar with the latest literature. Only one-third of participants reported having had received formal training in smoking cessation. Overwhelmingly, more training was reported as necessary and welcomed by participants. CONCLUSION: Our study has identified gaps in psychiatrists' and psychiatry registrars' knowledge and confidence regarding the promotion, initiation and oversight of smoking cessation strategies for patients. It's important that psychiatrists lead the way in re-framing and engaging with this issue, and consider smoking cessation as a tool that can improve mental health outcomes. A review of existing Australian policies, guidelines and training is recommended.

Supporting visitor compliance with a smoke-free policy at hospital using a nicotine replacement therapy vending machine.

ISSUE ADDRESSED: To support visitors to comply with Central Coast Local Health District's (CCLHD) smoke-free hospital grounds policy, a need was identified for round-the-clock availability of nicotine replacement therapy (NRT). Providing NRT through a vending machine was identified as a possible solution. This initiative complemented other strategies that provide staff and patients who smoke with NRT. METHODS: NRT was originally provided through a snack vending machine; however, there were commercial and regulatory concerns with this method. In 2015, dedicated NRT vending machines were installed at Gosford and Wyong Hospitals, and were operated by the Health Promotion Service. The appropriate regulatory permission was gained to supply a specific brand of NRT. Sales and incident data were recorded, and ongoing smoking counts were performed both before and after installation. RESULTS: In all, 247 sales of NRT gum were made through the vending machines from early 2017 to late 2019. Smoking counts show that there are very low rates of visitor smoking (<1%) in the approximately 4.5 years pre- and post-installation of dedicated vending machines. There was no statistically significant change in the smoking rate of visitors since the vending machine was installed at Wyong Hospital. CONCLUSIONS: While NRT is generally provided to patients and staff within health settings to support compliance with smoke-free policies, alternatives to smoking for visitors are typically overlooked. A NRT vending machine achieves this. However, because there are few purchases made, the vending machines as currently operating are unlikely to make any significant impact on smoke-free policy compliance at these hospitals. SO WHAT?: While vending machines have limited effectiveness on overall smoke-free policy compliance, this strategy may have applicability to all sectors with smoke-free policies, especially those operating 24 hours a day, as a means of providing an alternative to smoking for visitors.

Implementing and enforcing a smoke-free policy and by-law on hospital grounds at Central Coast Local Health District.

ISSUE ADDRESSED: Smoking by patients, staff and visitors on the grounds of Central Coast Local Health District (CCLHD). METHODS: NSW Health introduced a smoke-free buildings and vehicles policy in 1988. A smoke-free grounds policy was implemented in 1999, and a smoke-free by-law adopted by CCLHD in 2013, making smoking on CCLHD grounds an offence. Smoking in high-profile areas near hospital entrances was counted regularly since 2000. Several methods for communicating, monitoring and enforcing these smoke-free interventions have been adopted, including signage, Public Address announcements and enforcement patrols to ensure by-law compliance and to issue fines where required. Compliance with the smoke-free interventions has been supported with the availability of Nicotine Replacement Therapy for patients and visitors. RESULTS: When monitoring counts first commenced in 2000, smoking rates in high-profile areas were 8.1% at Gosford Hospital and 11.1% at Wyong Hospital. Counts conducted in 2018 indicated a substantial improvement, with the smoking rate in high-profile areas reducing to 0.25% at Gosford Hospital and 0.5% at Wyong Hospital. Smoking rates in high-profile areas have held steady at approximately 0.3% since 2014, after the by-law was implemented. CONCLUSIONS: The introduction of the smoke-free by-law added extra impetus to efforts to reduce smoking on CCLHD hospital grounds by providing the option to fine people who breach the by-law. Smoking in high-profile areas has declined substantially since 2011, and is minimal since the establishment of the smoke-free by-law. SO WHAT?: The experiences of CCLHD in implementing the smoke-free by-law may provide insights for other health services looking to use a similar intervention at their facilities. There are also methodological lessons for other organisations looking to communicate, monitor and enforce smoke-free policies, without enforcing fines.

Five years of health promoting work with bottle shops on the Central Coast of NSW Australia. How can we best ensure outlets check ID?

ISSUE ADDRESSED: Australian surveys indicate that a large proportion of packaged liquor outlets do not check identification for young people before selling alcohol to them. There are a substantial number of presentations to Emergency Departments from young people aged 15 to 17 years. This subgroup is second only to those aged 18 to 24 years. In the 15- to 17-year-old age group, supply from direct purchase or underage friends, who have purchased alcohol, represents substantial sources of alcohol that is more likely to be consumed without parental supervision. METHOD: Teenagers 18-19 years of age approached a randomly selected sample of bottle shops, on the NSW Central Coast Region, to attempt to purchase alcohol without producing identification (ID). Legally we are unable to test with teens under the age of 18. If outlets do not check ID for customers 18 or 19 years of age, we propose they might not check identification for 15- to 17-year-olds. A raft of local interventions was employed over four-survey periods to attempt to reduce selling rates. RESULTS: The lowest alcohol sales without ID occurred in 2015 when NSW Liquor and Gaming successfully prosecuted a Central Coast outlet for an underage sale. The rate of alcohol sales without checking ID each year was as follows: 2012-43.8%, 2014-37.55%, 2015-21.5% and 2016-45%. CONCLUSION: Alcohol sales to young customers without checking ID are common, widespread and seemingly resistant to nonpunitive interventions. The NSW Liquor Act could be modified to allow compliance testing and much more practical enforcement. While Central Coast bottle shops have a better record than other Australian areas showing some improvements with our nonpunitive industry education interventions, the results need to improve substantially to stifle primary supply.

Restricting the retail supply of tobacco to minors.

To examine the impact of enforcement of age-restricted tobacco sales on adolescent tobacco purchasing and smoking, we compared the Central Coast intervention area to the rest of New South Wales (NSW) and Australia. We collected data on students in school years 7-12 from triennial health surveys at baseline in 1993 through 2002. Attempts by minors to purchase tobacco in the intervention area declined by 73.6 per cent between 1993 and 2002. Between 1993 and 1996 the prevalence of smoking declined in the Central Coast intervention area, while remaining unchanged in NSW as a whole and nationally (P<0.0001). Between 1993 and 2002, the prevalence of current smoking in the intervention area was reduced by half. Effective enforcement of an age-restricted tobacco sales law was accompanied by a substantial reduction in attempted purchases of tobacco and of smoking by youth. The long-term follow-up in this study allows us to observe that the impact of the intervention was not only sustained but also increased with time.

Cannabis and driving: a new perspective.

Cannabis and driving is an emerging injury-prevention concern. The incidence of driving while affected by cannabis is rising in parallel with increased cannabis use in the community. Younger drivers are at particular risk. Improvements in research methodology, technology and laboratory testing methods have occurred in the last 10 years. These cast doubt on earlier results and conclusions. Studies now show that cannabis has a significant impairing effect on driving when used alone and that this effect is exaggerated when combined with alcohol. Of particular concern is the presence of cannabis as the sole psychoactive drug in an increasing number of road fatalities and the lack of any structural response to this problem. A review of testing methods, laboratory and real driving studies, and recent epidemiological studies is presented. Suggestions for methods of further data collection and future public policy are made.