Strong and healthy futures for Aboriginal and Torres Strait Islander people requires engagement in meaningful decision making which is supported by evidence-based approaches. While a significant number of research publications state the research is co-designed, few describe the research process in relation to Indigenous ethical values. Improving the health and wellbeing of Aboriginal and Torres Strait Islander mothers and babies is crucial to the continuation of the oldest living culture in the world. Developing meaningful supports to empower Aboriginal and Torres Strait Islander mothers to quit smoking during pregnancy is paramount to addressing a range of health and wellbeing outcomes. Aboriginal and Torres Strait Islander women have called for non-pharmacological approaches to smoking cessation during pregnancy. We describe a culturally responsive research protocol that has been co-designed and is co-owned with urban and regional Aboriginal communities in New South Wales. The project has been developed in line with the AH&MRC’s (Aboriginal Health & Medical Research Council) updated guidelines for ethical research with Aboriginal and Torres Strait Islander communities. Ethics approvals have been granted by AH&MRC #14541662 University of Newcastle HREC H-2020-0092 and the Local Health District ethics committee 2020/ETH02095. Results will be disseminated through peer reviewed articles, community reports, infographics, and online social media content.

Through the lens of complexity, we present a nested case study describing a decolonisation approach developed and implemented by Waminda South Coast Women’s Health and Welfare Aboriginal Corporation. Using Indigenous research methods, this case study has unfolded across three phases: (1) Yarning interviews with the workforce from four partner health services (n = 24); (2) Yarning circle bringing together key informants from yarning interviews to verify and refine emerging themes (n = 14); (3) Semi-structured interviews with a facilitator of Waminda’s Decolonisation Workshop (n = 1) and participants (n = 10). Synthesis of data has been undertaken in stages through collaborative framework and thematic analysis. Three overarching themes and eight sub-themes emerged that centred on enhancing the capabilities of the workforce and strengthening interagency partnerships through a more meaningful connection and shared decolonisation agenda that centres Aboriginal and Torres Strait Islander families and communities. Health and social services are complex systems that function within the context of colonisation. Waminda’s innovative, model of interagency collaboration enhanced workforce capability through shared language and collective learning around colonisation, racism and Whiteness. This process generated individual, organisational and systemic decolonisation to disable power structures through trauma and violence informed approach to practice.

Objective: To describe smoking characteristics, quitting behaviour and other factors associated with longest quit attempt and the use of nicotine replacement therapy (NRT) and stop-smoking medication (SSM) in a population of Indigenous Australian women of reproductive age.Design, setting and participants: A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020. Main outcome measures:Quitting experience: attempt to cut down, time since last quit attempt, longest period without smoking, attempt to cut down during last quit attempt, any use of NRT and/or SSM.Results: Most of the 428 participating women (302 [70.6%]) reported using an Aboriginal health service. Younger women (16-20-year-olds) smoked fewer cigarettes daily (24/42 [57.1%], 0-5 cigarettes per day), waited longer to smoke after waking (20/42 [47.6%], > 60 minutes after waking), and were categorised as low smoking dependency compared with those aged 35 years and over. One-third of women (153 [35.7%]) had ever used NRT and/or SSM. A greater proportion of older women (35-49-year-olds) had sustained a quit attempt for years (62/149 [45.6%]) and reported trying NRT and/or SSM (78/149 [52.4%]) than women in younger age groups. Quitting suddenly rather than gradually was significantly associated with sustained abstinence (prevalence ratio, 1.27 [95% CI, 1.10-1.48]). Among women who had never used NRT or SSM, most (219/275 [79.6%]) reported reasons for this in the category of attitudes and beliefs. NRT and SSM use was also more likely among women who were confident talking to their doctor about quitting (odds ratio, 2.50 [95% CI, 1.23-5.10]) and those who received most of their information from a health professional (odds ratio, 1.71 [95% CI, 1.11-2.63]). Conclusion:Aboriginal and Torres Strait Islander women want to quit smoking and are making attempts to quit. Quitting suddenly, rather than reducing cigarette consumption, is associated with increased sustained abstinence. Health providers can enable access and uptake of NRT and/or SSM and should recognise that NRT and/ or SSM use may change over time. Consistent messaging, frequent offers of smoking cessation support, and access to a range of smoking cessation supports should be provided to Aboriginal and Torres Strait Islander women to enable them to be smoke-free.The known: National priorities to reduce smoking rates during pregnancy among Aboriginal and Torres Strait Islander women are in place, but little published evidence exists to inform strategies to address these priorities.The new: Aboriginal and Torres Strait Islander women are making quit attempts and 36% have used nicotine replacement therapy and/or stop-smoking medications. Age, measures of nicotine dependence and remoteness are not associated with sustained quitting. Quitting suddenly, rather than reducing cigarette consumption, is associated with sustained abstinence.The implications: Health providers should suppo...

moking during pregnancy is the most significant modifiable risk factor linked to adverse pregnancy and long term health outcomes for both expecting mother and child. 1 Out of every ten Aboriginal and Torres Strait Islander women who smoke, only one successfully quits during pregnancy, 1 so smoking during pregnancy is a recognised factor in the current health, wellbeing and life expectancy inequalities experienced by Aboriginal and Torres Strait Islander people. 2 The higher prevalence of tobacco use among Aboriginal and Torres Strait Islander women during the perinatal period is directly linked to colonisation and other social determinants of health.Access to appropriate cessation supports, particularly in the primary care setting, is known to increase quitting rates in the general population. 3,4 Smoking cessation guidelines from the Royal Australian College of General Practitioners recommend integrating brief advice for all smokers during routine appointments, and follow-up for those making a quit attempt. This places health professionals in a key role in cessation care. 5 Behavioural support and counselling, coupled with first line pharmacotherapy (where appropriate) and follow-up, is recommended as best practice. 5 Among the general population, accessing and engaging with cessation support options, such as Quitline, can increase quitting success by 25% compared with pharmacotherapy alone. 6 Further, Australian health promotion initiatives have increased referrals to and uptake of cessation support services. 7 It is critical to recognise that current guidelines and recommendations for best practice smoking cessation draw on general population evidence, and do not always reflect the unique needs of Aboriginal and Torres Strait Islander people. There is new and emerging evidence for individualised support strategies, including mobile phone apps, 8 text message-based

Background Despite the high incidence of chronic obstructive pulmonary disease (COPD) in Aboriginal communities in Australia, Aboriginal Health Workers (AHWs) have limited knowledge about effective management. Aim To evaluate an online education program, co-designed with AHWs and exercise physiologists (EPs) or physiotherapists (PTs), to increase knowledge about COPD and its management. Methods AHWs and EPs from four Aboriginal Community Controlled Health Services (ACCHS) were recruited. An Aboriginal researcher and a physiotherapist experienced in COPD management and pulmonary rehabilitation (PR) delivered seven online education sessions. These sessions used co-design principles and an Aboriginal pedagogy framework ‘8 Ways of learning’, which incorporates Aboriginal protocols and perspectives to realign teaching techniques and strengthen learning outcomes. Topics covered were: How the lungs work; What is COPD; Medications and how to use inhalers and COPD Action Plans; Why exercise is important; Managing breathlessness; Healthy eating; Managing anxiety and depression. After each session, AHWs with support from EPs, co-designed education ‘yarning’ resources using Aboriginal ways of learning to ensure topics were culturally safe for the local Aboriginal community and practiced delivering this at the following session. At the end of the program participants completed an anonymous online survey (5-point Likert scale) to assess satisfaction, and a semi-structured interview about their experience of the online education. Results Of the 12 participants, 11 completed the survey (7 AHWs, 4 EPs). Most (90%) participants strongly agreed or agreed that the online sessions increased knowledge and skills they needed to support Aboriginal patients with COPD. All (100%) participants felt: their cultural perspectives and opinions were valued and that they were encouraged to include cultural knowledge. Most (91%) reported that delivering their own co-designed yarning scripts during the online sessions improved their understanding of the topics. Eleven participants completed semi-structured interviews about participating in online education to co-design Aboriginal ‘yarning’ resources. Themes identified were: revealing the Aboriginal lung health landscape; participating in online learning; structuring the online education sessions; co-designing with the facilitators. Conclusions Online education using co-design and 8 Ways of learning was rated highly by AHWs and EPs for improving COPD knowledge and valuing cultural perspectives. The use of co-design principles supported the cultural adaptation of COPD resources for Aboriginal people with COPD. Trial registration PROSPERO (registration number: CRD42019111405).