The Medical Link – Issue 146

medical link THE OFFICIAL PUBLICATION OF THE GOLD COAST MEDICAL ASSOCIATION INC.

The Countdown to Samoan Medical Conference Begins The GCMA and SMoH, SMA, NSU, OUM Medical Conference will cover a very wide range of topics corresponding to the health problems currently affecting Samoa, including non-communicable diseases (diabetes, cardiovascular, cancer and obesity), mental health, and infectious diseases.

ISSUE 146 | AUGUST – SEPTEMBER 2023

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THE MEDICAL LINK •

Contents 06 A Message From the GCMA President Prof Philip Morris AM FEATURE STORY 14

17

The Countdown to Samoan Medical Conference Begins Prof Stephen Weinstein Samoan Medical Conference Program

EDITORIALS 12

Informed Management of Benign Oesophageal Disorders Utilising Oesophageal Physiology Testing Dr Candice Silverman and Dr Anna Isaacs

20

Setting Up Your Professional Practice Right From the Outset Bank of Queensland

22

The Effect of Education and Other Socioeconomic Factors on Smoking Status in Western Australia Walter Chukwunonso Ikealumba

Cover Credit: Free Vector Maps Other Credits: Pexels, Unsplash & Freepik medicallink.com.au • 5

• THE MEDICAL LINK

A Message from the GCMA President Prof Philip Morris AM, President GCMA MB BS BSc PhD FAChAM (RACP) FRANZCP FPOA FFP ABPN info@drphilipmorris.com | 0422 545 753 | www.drphilipmorris.com

Dear GCMA colleagues,

H

ow time zooms along! We are now into the second half of the year and only a short time away from the GCMA Samoa Medical Conference in Apia, Samoa from 29-30 September. We are looking forward with great anticipation to this meeting with our South Pacific medical colleagues and students. The program has a wide topic compass and the speaker contributions are equally shared between our Samoan colleagues and our GCMA sourced presenters. More details of this conference are included in this edition of The Medical Link.

Medical Association, the National University of Samoa, and the Samoan Ministry of Health. We have received very welcome sponsorship support from Griffith and Bond Universities. I hope you will join us in Samoa in September. Everyone is welcome! Conference attendees get a substantial discount on accommodation at the meeting venue, the fantastic Taumeasina Island Resort.

I want to thank A/Prof Stephen Weinstein for his sterling efforts in bringing this meeting together in collaboration with our conference partners the Oceania University of Medicine, the Samoan

PAEDIATRIC NUTRITION: FEEDING BASICS TO SUPPORT THE LITTLEST PEOPLE Sports & Spinal Dietitians offer individualised advice and can help to translate the latest evidence into practical steps to guide you in the right direction toward better health.

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SCAN THE QR CODE FOR MORE INFORMATION

To register, please scan the QR code below, or simply Google ‘GCMA Samoa Conference’.

On Thursday 20 July we had our first evening clinical dinner meeting in our new venue at Bumbles Café and Restaurant at Budds Beach, Surfers Paradise. The informative and well-illustrated presentation on radiation therapy for skin cancers by Dr David Christie, Radiation Oncologist from Genesis Care, opened up a range of treatment options for patients suffering from solar-caused skin conditions. An article arising from this presentation will be forthcoming in The Medical Link.

The new venue was a more intimate setting for our meetings and I would like to thank the Bumbles staff for the wonderful service and food! We plan more Thursday evening meetings at Bumbles later this year.

Below are some of the key points of feeding and eating for paediatric clients:

Breathing Posture Gut Function Mealtime Distractions Food Progression There are many other considerations for feeding and eating in paediatric clients, and it is important to speak with a Dietitian about any other concerns that they can support.

Get in touch with your local Sports & Spinal Dietitian to learn more.

THE GCMA PRESIDENT'S REPORT •

Artificial Intelligence We have seen much written recently about artificial intelligence (AI) ‘taking over’ medical practice. I was asked what I thought of the place of AI (and more specifically the Chat-GPT version of the machine learning form of AI) in medicine. After some reflection my response was, “It is good for scoping an issue or problem, but cannot be the final word”.

I still think that is a reasonable response, but I thought I would get a second opinion from the ‘horse’s mouth’ so to speak; from GPT-4 (the latest version of Chat-GPT). I asked this AI machine to: “Please write a short piece on the positives and negatives of using artificial intelligence machines like GPT-4 in medical practice”.

GPT-4 responded: Title: The Pros and Cons of Integrating GPT-4 AI Machines in Medical Practice In recent years, the rapid advancements in

artificial intelligence (AI) have opened up new possibilities for the medical field. The introduction of GPT-4 AI machines holds promise in revolutionizing healthcare delivery. However, like any technology, there are both positive and negative aspects to consider when integrating AI, such as GPT-4, into medical practice.

The Positives: 1. Enhanced Diagnostic Accuracy: GPT4 AI machines have the potential to analyze vast amounts of patient data, including medical records, lab results, and imaging scans, allowing for more precise and rapid diagnoses. This can lead to early detection of diseases and improved treatment outcomes.

2. Efficient Data Processing: AI machines can sift through mountains of medical data in a fraction of the time it would take for human clinicians. This efficiency can save precious time and resources, en-

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abling medical professionals to focus more on patient care and research.

3. Personalized Treatment Plans: By leveraging AI's ability to identify patterns and trends in patient data, GPT-4 can assist in developing personalized treatment plans.

Tailoring treatments to individual patients can optimize therapeutic effectiveness and reduce adverse effects.

4. 24/7 Availability: AI machines don't suffer from fatigue or require rest, enabling them to work around the clock.

This continuous availability ensures quick access to medical information and decision-making support, particularly in emergencies.

The Negatives: 1. Data Privacy and Security Concerns: Integrating AI systems in medical practice requires sharing sensitive patient data. Ensuring

• THE MEDICAL LINK

data privacy and protecting against cyber threats becomes paramount, as breaches could have severe consequences for patient trust and well-being.

2. Lack of Human Intuition: AI machines lack the empathetic and intuitive qualities of human clinicians.

While AI can provide data-driven insights, it may not fully comprehend the emotional and psychological aspects of patient care, which are crucial in certain medical scenarios.

3. Bias in Data and Algorithms: If the training data used to develop GPT-4 AI machines is biased or limited in representation, the AI system might perpetuate existing healthcare disparities. This bias could lead to differential treatment or misdiagnoses, particularly for underrepresented patient groups.

4. Limited Understanding of Complex Cases: Although GPT-4 can process large amounts of data, there are cases

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THE GCMA PRESIDENT'S REPORT •

where the medical situation is highly complex and requires a deep understanding of unique circumstances.

AI systems may struggle to handle such complex scenarios accurately.

5. Liability and Accountability: When AI is involved in decision-making, questions of responsibility and liability arise. Determining who is accountable in cases of medical errors or adverse outcomes involving AI can be legally and ethically challenging.

In conclusion, integrating GPT-4 AI machines in medical practice brings about a host of opportunities and challenges.

While it has the potential to enhance diagnostic accuracy, improve treatment plans, and optimize healthcare delivery, concerns related to data privacy, bias, lack of human intuition, and accountability must be addressed carefully. Striking the right balance between AI assistance and human expertise will be crucial to unlock the full potential of AI in advancing

healthcare while ensuring patient safety and well-being.

Well, this seems a reasonable response from GPT-4. It will be interesting to see how the application of AI in medical practice plays out. But I am optimistic that ways of using AI to compliment rather than compete with doctors will be the way forward.

We are always looking to expand our membership. I encourage you to invite your doctor colleagues to join the GCMA. It is very easy to do. Just go to the GCMA website (www.gcma.org.au) and click through to the ‘Become a Member’ page to join. The registration page can take credit card payments. The $150 annual membership is extremely good value. It covers Thursday evening meetings where salient updates on clinical and professional matters are presented as well as a two-course meal and complimentary beverage, and the opportunity to interact with colleagues from all professional

disciplines. I would like to thank those members who have renewed their membership for 2023. Your support is always appreciated. The GCMA is always ready to welcome new members to the leadership team. Please give me a call on phone number is 0422545753 if you are interested.

I look forward to seeing you at the Medical Conference in Samoa!

Yours sincerely, Prof Philip Morris AM President GCMA

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DISCLAIMER: The contents of articles and opinions published are not necessarily held by the publisher, editor or the Gold Coast Medical Association. No responsibility is accepted by the publisher, editor or Gold Coast Medical Association for the accuracy of information contained in any opinion, information, editorial or advertisement contained in this publication and readers should rely upon their own enquiries in making decisions touching own interest. Unless specifically stated, products and services advertised or otherwise appearing in The Medical Link are not endorsed by the publisher, editor or the Gold Coast Medical Association.

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MEDICAL EDITORIAL COMMITTEE

Philip Morris, Geoff Adsett, Stephen Withers, John Kearney, Maria Coliat

GCMA MEMBERS gcma.org.au

GCMA EXECUTIVE COMMITTEE

President Prof Philip Morris 5531 4838 Vice-President Dr Maria Coliat 5571 7233 Secretary Prof Philip Morris 5531 4838 Immediate Past President Dr Sonu Haikerwal 5564 6255 Treasurer Dr Geoff Adsett 5578 6866 Specialist Representative Prof John Kearney 5519 8319 GP Representative Dr Katrina McLean 5564 6501 Academic Representative Prof Gordon Wright 5595 4414

Keeping the Medical Community Informed The Medical Link enriches the Gold Coast medical community by uniting the voice of its doctors.

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We invite you to submit your company updates, new recruits and promotions to the following email: admin@themedicallink.com.au And if you would like to advertise your products or services, positions vacant, rooms for rent etc. in The Medical Link, please feel free to contact us admin@themedicallink.com.au.

"Oesophageal physiology testing offers a valuable tool for healthcare professionals to determine the appropriate treatment in terms of medications and surgery."

12 • Issue 146

Informed Management of Benign Oesophageal Disorders Utilising Oesophageal Physiology Testing Dr Candice Silverman and Dr Anna Isaacs MBBS (Hons), FRACS, ANZGOSA and BSc, MBBS, FRACS, ANZGOSA Suite G, 42 Inland Drive, Tugun, QLD 4224 (07) 5598 0955 | admin@corespecialistgroup.com.au | www.corespecialistgroup.com.au

O

esophageal physiology testing, encompassing Oesophageal Manometry and pH testing, has revolutionised the diagnosis of gastroesophageal conditions.

It can be considered an adjunct to a good history, radiological examination (contrast swallow or CT scan) and endoscopy. Non cardiac chest pain, reflux and difficulty swallowing are among the indications.

Patients with oesophageal symptoms are often referred for endoscopy to exclude mucosal or structural pathology. If endoscopy is normal and/or patients fail to respond to Proton Pump Inhibitors (PPIs), oesophageal manometry and ambulatory pH testing can be considered.

It is important also that some form of imaging (contrast swallow or CT scan) be done in preparation for physiology studies. Contrast swallow fluoroscopy gives us some idea of oesophageal function and hiatal anatomy whilst CT scan with oral contrast gives us a great understanding of anatomy only. It is important to have this information as there is a complex interplay between anatomy and physiology, specifically the relationship of the oesophagus to the diaphragm. If there is a massive hiatus hernia i.e., most of the stomach is in the chest then physiological testing is not able to be performed.

Patients with a massive hiatus hernia require referral to a surgeon for hiatal hernia repair.

High resolution manometry involves a fine nasogastric tube being placed, and swallowing tests performed.

The manometry catheter has sensors every 2cm along the length of the oesoph-

agus. Spatiotemporal and topographical representation of the pressure data provides a visual representation of oesophageal pressure from pharynx to stomach.

O

esophageal Manometry can aid in evaluating oesophageal motility, identifying any abnormalities that may contribute to reflux, and diagnosing motility disorders such as achalasia.3 For 24-hour ambulatory pH testing, a pH sensing catheter is placed 5cm above the manometrically defined lower oesophageal sphincter. For best results patients should be off all their acid suppressing medication for two weeks. Patients are asked to perform all their usual activities as much as is possible whilst the probe is in place. They record meals, supine moments, and specific symptoms.

The probe is removed and the data is analysed. It can help to answer questions such as: 1. Is what the patient describes as “reflux” really gastro-oesophageal reflux?

2. Is the refluxate acid in nature?

3. What is the likelihood of the patient benefiting from anti-acid medication or from anti-reflux surgery?

O

esophageal physiology testing offers a valuable tool for healthcare professionals to determine the appropriate treatment in terms of medications and surgery. By assessing oesophageal pH levels and correlating them with symptoms, clinicians can establish the presence and severity of acid reflux, aiding in maintaining PPI stewardship. A definitive diagno-

sis of reflux aids in selecting patients for surgical treatment (fundoplication) for reflux.

Oesophageal physiology testing, encompassing Oesophageal Manometry and pH testing, has improved the diagnostic landscape for various gastroesophageal conditions. Oesophageal physiology testing has an important role in assessing the function of the oesophagus and stomach to guide clinical practice.

D

r Anna Isaacs and Dr Candice Silverman, Upper GI, Hernia and Metabolic Surgeons, are pleased to announce that they are commencing oesophageal manometry testing and 24-hour pH monitoring at John Flynn Private Hospital from 30 June 2023.

References 1. Lata T, Trautman J, Townend P, Wilson RB. Current management of gastro-oesophageal reflux disease—treatment costs, safety profile, and effectiveness: a narrative review. Gastroenterology Report.

2023;11 doi:10.1093/gastro/goad008.

2. Heinrich H, Sweis R. The role of oesophageal physiological testing in the assessment of noncardiac chest pain.

Therapeutic Advances in Chronic Disease.

2018;9(12):257-267. doi:10.1177/2040622318791392.

3. Sweis R, Fox M. High-Resolution Manometry—Observations After 15 Years of Personal Use—Has Advancement Reached a Plateau? Current gastroenterology reports. 2020;22(10):49-49. doi:10.1007/s11894-020-00787-x.

medicallink.com.au • 13

FEATURE STORY •

The Countdown to Samoan Medical Conference Begins Prof Stephen Weinstein MHA, FRCPA, FRACMA, FACHSE stephenweinstein@bigpond.com

P

lanning for the joint GCMA medical conference in Samoa (28-30 September, 2023) began more than a year ago, when we were still partially under the dark cloud of Covid restrictions. Fortunately, travel to Samoa has become a lot easier, also because direct flights from Brisbane to Apia have resumed earlier this year. The conference program is now in the final stages of completion. To give you an idea of the scope and topics covered by both Australian and Samoan speakers, please see the conference program on the following spread.

T

he GCMA has a history of Pacific partnerships, with Dr Vijay Kapadia being a driving influence for our first joint conference in Fiji in 2009, when our partner organisations were the Fiji College of General Practitioners, and the Fiji Medical Association. This was followed up by a further well attended joint conference in Fiji in 2015, this time opened by the Fiji Minister of Health. In 2017 we held a meeting in Vila, Vanuatu, with the Vanuatu Medical and Dental Association. Dr Sale Vurobaravu, an enthusiastic young Ni-Van doctor, was our counterpart on the steering

committee, emphasising how essential it is to have helpful, local support to make such an event a success. amoa has an interesting history, becoming the first independent nation in the South Pacific in 1962 (apart from Tonga, which always retained its independent monarchy). Back in 1889, Samoa was engaged in a three-way civil war between rival chiefs, with each side supported by Britain, Germany and the US. A great hurricane that year wrecked most of the foreign warships in Apia harbour, putting a damper on military activities. At the same time the author Robert Louis Stevenson (Tusitala – teller of stories in Samoan) was living in Apia, and was much loved by the local people. (His house Vailima is a major attraction in Samoa, and his mountaintop grave can also be visited). The conflict was resolved by partition in 1899, with the larger Western islands of Upolu and Savaii going to Germany, and Tutuila, with its natural harbour of Pago Pago, becoming American Samoa, which it still is today. German Samoa was taken by a New Zealand expeditionary force in 1914, and ruled by Wellington until 1962.

S

O

ur partner organisations this time will be primarily the Oceania University of Medicine

(OUM, see their website), headed by the Brisbane based Vice Chancellor Prof Hugh Bartholomeusz. Dr Laumeko is the Dean for Samoa, and there are also Deans for Australia and the USA, where many of the students come from.

The OUM is a private fee-paying medical school, and my wife Lis and I spent some very rewarding time teaching there in 2008. We taught mostly the Samoan medical students, because the Australian and US students spend the majority of the course on attachments in their home countries. The Samoa Medical Association, the National University of Samoa, and the Ministry of Health are likely to be the other partners.

When we discussed what contribution our speakers could make, Dr Laumeko outlined a very wide range of topics corresponding to the health problems currently affecting Samoa, including non-communicable diseases (diabetes, cardiovascular, cancer and obesity), mental health, and infectious diseases.

The other major contribution that the GCMA could make to the OUM would be to assist with the placement of medical students in hospitals and private practices, which we expect to hear more about later.

As part of the conference planning process, as we did in Fiji and Vanuatu, a site visit to meet our Samoan counterparts occured in the second half on this year 2022. Please go ahead and register for the conference if possible, and spread the word to your families and colleagues (the dates deliberately coincide with the Queensland school holidays).

Please refert to conference program on following spread.

medicallink.com.au • 15

"When we discussed what contribution our speakers could make, Dr Laumeko outlined a very wide range of topics corresponding to the health problems currently affecting Samoa, including non-communicable diseases (diabetes, cardiovascular, cancer and obesity), mental health, and infectious diseases."

16 • Issue 146

SAMOA 2023 MEDICAL CONFERENCE PROGRAM •

The GCMA and SMoH, SMA, NSU, OUM Medical Conference Taumeasina Resort – Apia, Samoa 28-30 September 2023

medicallink.com.au • 17

• THE MEDICAL LINK

18 • Issue 146

SAMOA 2023 MEDICAL CONFERENCE PROGRAM •

Certificates of attendance for 12 hours of CPD and CME will be available to participants.

medicallink.com.au • 19

There are many advantages to choosing an escrow facility over other finance options when it comes to buying what you need to open your new practice.

20 • Issue 146

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pproaching the set-up of your new practice the right way can help you get one step ahead. It's an exciting time, and you will likely want everything in place from day one. The decisions you make around the equipment, the layout, and even the look and feel of your practice will contribute to its ongoing success.

However, the cost of practice fit-outs for a start-up can be up to $500,000, so it’s useful to have a clear idea on what your financing options are.

Some of your assets, like equipment, will be income-producing from the beginning. Others, such as software, will be higher depreciating assets. That's why it’s more important that your financing demands are in line with revenues from the outset. The real question to ask is whether that particular piece of equipment or soft cost can wait for a few months until you’re generating income. If it can, then it’s best to hold tight—this will ease some of the cash flow pressure and help you navigate the first few months. Equipment shelf life and industry trends are also important aspects to consider. What seems like cutting-edge gear today can be out of date in a few years. Taking into account the lifetime of a product is essential, as you will want to ensure it pays for itself, as well as assessing its impact on your cash flow.

On the other hand, if it can’t wait and needs to be ordered or installed from the start, there are finance options like an escrow facility which can help with the scheduling of repayments to best suit your needs.

Why escrow?

W

hile a loan or even a credit card are common financing options for fitting out your practice, another option

to consider is an escrow facility. This is a master limit facility which can be progressively drawn as you need during the fit-out. The escrow facility allows you to pay any supplier related to the fit-out at your discretion or you can acquire assets using your own funds and reimburse under the facility. In using the escrow facility you are only charged for the funds you use, when you use them.

One of the key advantages of an escrow facility is that it allows you to make variations or changes along the way. It's not uncommon during a fitout to decide on higher-end furnishings or different office equipment than first anticipated. An escrow facility allows you the flexibility to do that. It is common, for example, for a client to take out a $500,000 limit and then only end up needing $400,000. However, you're not going to pay for that extra $100,000 unless you actually use it.

Another benefit is that an escrow facility wraps up all the financial elements of a fit-out into one simple lending agreement. As the invoices can come at different times from different vendors, these are instead managed by the bank rather than the practice owner. The payments are made on your behalf via the escrow facility and a full record of all transactions is maintained. Then at the end of the fit-out period, the escrow facility is converted into a lease or loan facility or split between both, depending on what is most advantageous for your business’ tax and cash flow needs.

The final key benefit of an escrow facility is that you don't make any payments until the project finishes.

The final amount loaned can be rolled into a longer term agreement, such as a chattel mortgage or a lease with fixed or structured repayments. This makes an

escrow facility an attractive option for new practice owners as you won’t have to start paying off your fit-out until it is complete and the doors are open for business.

Why BOQ Specialist?

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nowing the market and the right questions to ask when dealing with suppliers can make all the difference.

BOQ Specialist has helped finance many practice fit-outs, and know that there are smaller intangible cash flow costs associated with a fit-out. That’s why in addition to the escrow facility, they can provide a cash flow solution via an overdraft facility to manage the initial and ongoing cash flow needs of the business. Understanding the financing options available to you can make the world of difference. Whether you’re just getting started or setting up your fourth practice, BOQ Specialist’s 30+ years of industry experience means they can tailor solutions built around the strength of your qualifications.

To find out more, visit boqspecialist.com. au or contact your local finance specialist on 1300 160 160.

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medicallink.com.au • 21

• THE MEDICAL LINK

The following article is the work of a student of the Oceania University of Medicine, which is our partner organisation for the upcoming medical conference in Samoa, 28-30 September, 2023.

The Effect of Education and Other Socioeconomic Factors on Smoking Status in Western Australia Walter Chukwunonso Ikealumba PhD CHE, BEng ME (Hons), MIEAust, MIIMarEST walter.ikealumba@oum.edu.au

Abstract

T

he health and economic consequences of tobacco use are drastic, with life expectancy of smokers reduced by 15 years due to tobacco-related illnesses.

Few studies have addressed the effects of education and socioeconomic factors on smoking status in the Australian population. Thus, the aim of this study, is to examine the association between education and other socioeconomic factors with smoking status among Western Australian residents. In addition, the study will also examine if smoking within the Western Australian population fits the current global smoking epidemic.

The study consisted of a sample size of 78 participants. A questionnaire was utilized to collect information on demographics, why individuals smoke/started smoking, and why individuals quit smoking.

The results showed that prevalence of smoking was highest within 40 – 49 age group and lowest within the 50+ age group. The results also showed that as education levels increased, the total number of smokers decreased; in addition, the percentage of heavy smokers also decreased.

The primary reason participants began smoking was peer pressure; and continue smoking because of stress. For those that did quit smoking, to avoid future health conditions, was the decisive factor.

This study showed that the age-related smoking status from a sample in Western Australia fits the global smoking epidemic trend. This study also illustrated the well-documented inverse association between education and smoking.

Given the effect of peer pressure, stress and health concerns on smoking hab-

22 • Issue 146

its, preventative and cessation strategies should be aimed at subgroups; with the most crucial subgroup being young adolescents.

Introduction

G

lobally, 19.2% of adults are smokers with men at 32.7% and women at 5.8%. [1] Overall, there are more than one billion smokers in the world. [1] The health consequences of tobacco use are drastic. The life expectancy of smokers is reduced by 15 years due to tobacco-related illnesses. [2] Tobacco-use kills more than 8 million people per year and more than half of all lifetime users. [2] In Australia, the trend is slightly favourable with only 11.6% of adults being smokers, men at 12.8% and women at 10.4%. [3] However smoking is still the leading cause of preventable disease in Australia; and is linked to numerous diseases, which place a national financial burden of $136.9 billion. [4] The global smoking paradigm can be broken into four stages. The first stage, 1900 – 1920, is when smoking was first introduced among men, especially those of a higher socioeconomic status, but was not very common among women. In the second stage, 1920 – 1950, smoking became a widespread middle class and working-class habit; as a result, smoking increased sharply with both men and women smoking. In the third stage, 1950 – 1980, smoking reached its peak, and slowly began to decline especially among those of high socioeconomic status. In the last stage, 1980 – 2000s, smoking declined to approximately 20%. [5] Even though the global trend of smoking is on the decline, the impact it

has on health and the economic system is still significant, which warrants the need to understand what causes people to smoke. Education is a social determinant of health, [6] and higher education has been linked with better mental health, longer life expectancy and better health related behaviour. [7] The knowledge of smoking and its risks is associated with education. [8] There is a strong inverse association between socioeconomic position, including education, and smoking.

[9] Smoking is higher in groups with less education. [7,10] Other studies focused directly on the cognitive ability of individuals; those with low cognitive ability are more likely to take up smoking and less likely to quit, compared to those with higher childhood cognitive ability.

[11] Interestingly, some studies pointed toward smoking as a coping strategy for poor educational performances and stress. [7,12] There is a clear inverse relationship between the level of education and smoking status and it is not surprising that within the global declining trend of smoking, this decline was noted more in those of higher education status.

[10,13] Even though numerous research point towards the link between low educational attainment and increased chances of smoking; some studies have concluded that low educational attainment not only increases the chances of smoking, but that smoking, can ultimately affect education status. [12,14] Its important to point out that education can be associated with whether individuals started smoking, but not whether they continued smoking. [11] This will be a crucial factor when targeting smoking cessation education and campaigns.

The socioeconomic position in young adolescent and early adulthood is the most important factors for determining the impact smoking will have on an individual’s life. [15] Initiation of smoking at this critical age group is associated with a large spectrum of personal and social disadvantage, with education being one of those disadvantages. [16] Smoking in this age group not only decreases the likelihood of enrolling into further education [12] but increases the likelihood of heavy smoking as the person ages. [7 Addressing smoking behaviours, therefore, should be focused on subgroups, [9] with prevention strategies aiming to reach young children during adolescence and continue to reinforce this into adulthood. [17] Smoking cessation, reduces mortality and doing so earlier in life, is associated with significant reductions in mortality. [18] However, it is important to determine why individuals continue smoking in the first place; studies have shown that they only stopped when there was a crucial reason or when they saw alternative ways of living. [19] Few studies have addressed the effects of education and socioeconomic factors on smoking status in the Australian population. Given the large impact of smoking to health care and mortality, it is crucial that the effects of education and

other socioeconomic factors are identified. This will enable us to target at risk groups more accurately with correct preventative and cessation measures. Thus, the aim of this study, is to primarily examine the association between education and other socioeconomic factors with smoking status among Western Australian residents. In addition, the study will also examine if smoking within the Western Australian population fits the current global smoking levels.

Method

T

his is a preliminary study with a sample size of 78. Data was collected over a period of approximately 3 months starting from 21/09/2021, from Palm Springs Pharmacy using a questionnaire, with an age group of 18 years and above.

The questionnaire collected information on sex, age, level of education attained, occupation, smoking status, why individuals smoke/started smoking, [20] and why individuals quit smoking. [21] Age group brackets were distributed as follows, 18 – 29, 30 – 39, 40 – 49, 50+.

The highest level of education attained includes primary school, high school, vocational education (tafe), university, these are the usually educational options in Australia. Six options were provided for

occupation, medical, engineering, hospitality, entertainment, student, unemployed/unable to work. The occupation options utilised in this study were selected to be all-encompassing of major industries, for example medial could include doctor, nurse, dentist, optometrist, pharmacy, and even receptionist within those establishments etc; engineering could include, engineers, mine workers, draftsmen, technicians, machinists etc; hospitality could include those in retail, restaurants etc; entertainment could include, musicians, actors and actresses, singers, night clubs, acrobats etc; students are those that are currently studying and not working; while unemployed/unable to work are those without any form of employment. There were three smoking status options either current smoker, previous smoker or never smoked. For current and previous smokers, reasons for starting smoking was analysed and includes some of the most common reasons people pick up smoking; [20] peer pressure, rebellious, stress, boredom or because family member smokes. For previous smokers, reasons for quitting was investigated and includes some of the most common reasons people quit smoking; [21] current health condition, to avoid future health condition, pregnancy related, family/ partner wanted you to stop, economic cost, smoking ban or other.

Informed consent was obtained from the participants and anonymity was guaranteed. IRB approval was requested and approved by Oceania University of Medicine. Budget – There was a gift card given to the random participants of the survey.

Once data collection was completed, all analysis was conducted via Excel.

Firstly, the prevalence of smoking within each age group will be analysed, which will assist in determining if smoking status among Western Australian residents fit the global smoking epidemic. Other demographic analysis such as comparing the incidence of smoking between different genders will also be conducted.

The effect of education on smoking will be investigated in addition to the occupation of the participants. It is important to determine the effect of occupation on smoking status, as there is a strong positive relationship between education and occupation. Those who smoke more than 20 cigarettes a day are considered heavy smokers and tend to have a shorter

medicallink.com.au • 23

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life expectancy. Therefore, it will be useful to identify the percentage of current smokers that fall into this category and the educational level of these smokers.

Finally, the analysis will be used to investigate the primary reasons underlying smoking, the continuation of smoking, and the cessation of smoking.

Statistical analysis – Not indicted for the proposed study.

Sample of the questionnaire is provided in the Table 7.

Results Table 1 summaries demographic characteristics of the study sample. Of the 78 participants, over 78% were female and approximately 77% were older than 40 years old. The highest level of education attained by participants was mainly high school, making up 43.6% of sample size, closely followed by vocational training at 34.6%. Unemployed/unable to work was the most frequent occupation, making up 28.2% of the sample size, however this was mainly due to a large portion of the participants being retired. Occupation across the medical, engineering and hospitality fields were relatively evenly distributed, at approximately 15%. Regarding smoking status of participants, approximately 48% were previous smokers, while current smokers and those who have never smoked are relatively evenly distributed.

Table 2 summaries information pertaining to current smokers. Of the 19 current smokers, 11 smoked less than 20 cigarettes per day, while eight were heavy smokers, smoking more than 20 cigarettes per day. Of these current smokers, 79% selected stress as the primary reason for smoking; while other reasons such as peer pressure, rebellious and boredom only make up small percentages. Whether a family member smokes, was not a reason for any of the current smokers to continue smoking.

Table 3 summarises information concerning previous smokers. Of the 38 previous smokers, 45% had peer pressure as the predominant reason why they started smoking, followed by being rebellious at 24%. Interesting, 16% of previous smokers started smoking because family members smoke, showing the effect that family members can have on individuals picking up smoking. Stress, at 5%, was the least reason why previous smokers started smoking, which possibly points to stress not being the main reason people start smoking. While the main reason for quitting was to avoid future health condition, followed by the family member wanting the individual to quit. This shows the effect that health education and family members can have on individuals achieving their smoking cessation goals. Current health condition was the least reason, at 5%, why previous smokers quit smoking, which is thought-provoking.

The prevalence of smoking, as seen in

Table 4, was highest within the 40 – 49 age group. The percentage of smokers in this age group was 40%. The frequency of smoking was lowest in the 50+ age group, at 10%. The data shows that as age group increases, the prevalence of smoking increases up to the 40 – 49 age group, where it peaked and then started to decrease.

Participants within the age groups of 18 – 29 are believed to be underrepresented, making up approximately 9% of the total sample size.

Figure 1 and Figure 2, show the smoking status of females and males respectively. The frequency of current smokers is higher in females compared to males, at 25% and 19% respectively. It’s interesting to note that in both genders approximately 50%, Figure 1 and Figure 2, are previous smokers. Whereas those who have never smoked is at approximately 25%.

The prevalence of smoking, stratified against the highest level of education attained is presented in Table 5. Of those that completed university studies only 7% were smokers, compared to 26% amongst those that only completed high school or vocational education. For those that stopped schooling after primary school, the sample size of two participants, is believed to be insufficient, to accurately represent the predominance of smoking within this group. The percentage of heavy smokers was highest, at 56%, for those that only completed high school; 25% for those that completed vocation training and 0% for those that completed university.

The prevalence of smoking by occupation is presented in Table 6. Participants unemployed or unable to work had the lowest rate of smoking, closely followed by those in the medical field, at 14% and 20% respectively. Engineering had the highest percentage of smokers, followed by those in the hospitality industry, 40% and 31% respectively. The sample size of students, including those in the entertainment industrial, as shown in Table 6, is believed to be insufficient, to accurately represent the smoking status within these groups.

Discussion

T

he prevalence of smoking, as seen in Table 4, was highest within the 40 – 49 age group. The percentage of smokers

24 • Issue 146

in this age group was 40%. This finding fits the global smoking epidemic, as the individuals in the 40 – 49 age group would have been born around 1950 – 1980 when smoking reached its peak [5,22] and therefore could easily have picked up smoking compared to other age groups.

The frequency of smoking was lowest in the 50+ age group, at 10%, Table 4. The lower prevalence of smoking in the 50+ age group, is perhaps due to increasing health concerns within this group due to their age. Cigarette smoking has declined significantly in most countries due to the awareness of the negative health impacts associated with smoking, including the implementation of smoke-free areas. This would have contributed to the decline of smoking also seen in this study as those in the 30 – 39 and 18 – 29 age groups showed reduced prevalence of smoking.

As presented in Table 1, of the 78 participants, 61 were females and only 16 were males. Globally and in Australia, the prevalent of smoking is highest amongst the male gender. [1,3] This was also illustrated in the global smoking epidemic with men picking up smoking as a habit before females eventually started smoking; and percentage of male smokers always remained higher than that of females. [5,22] However, the results in this study opposed this finding, by showing that the frequency of smoking is higher in females compared to males, at 25% and 19% respectively, Figure 1 and Figure 2. This perhaps could be attributed to the disparity between the sample size of females to males. It’s interesting to note that in both genders approximately 50%, Figure 1 and Figure 2, are previous smokers. We know that as individuals age, the likelihood to quit smoking due to health concerns increases; as is indicated in Table 3, with ‘to avoid future health conditions’ as the dominant reason. This correlates well with the age groups in this study, as majority of the male and female sample are in the 50+ age group, as shown in Table 4.

The strong inverse association between education and smoking is well-documented. [7,9-11,23] This association is also well represented in this study, as shown in Table 5. Higher educational attainment, resulted in reduced number of total smokers; with approximately 7% smokers amongst those that completed university level education, compared to

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26% amongst those that only completed high school or vocational education. This finding was expected as less educated individuals are less likely to gain the knowledge of the negative health impacts of smoking, compared to the more educated participants. [24] However, there are other explanations for the higher smoking rates in those with lower education levels.

Several studies have also pointed towards less favourable psychosocial conditions in those with lower education, such as poor coping resources, lack of opportunities for alternative leisure, or elevated levels of socio-emotional distress. [12,25,26] Not only would these less favourable psychosocial conditions contribute to the higher smoking rates seen in those with lower educational levels, but it would also contribute to the lack of further educational attainment in these individuals.

Education does play a big role in securing an occupation, and there is a strong positive relationship between education and occupation. As presented in Table 6, participants unemployed or unable to work had the lowest rate of smoking, closely followed by those in the medical field, at 14% and 20% respectively. However, a previous study pointed towards unemployment being a significant risk factor for smoking. [27] This opposes the results in our current study; however the results in this study were expected findings, as approximately 64% of the unemployed or unable to work, are individuals in the 50+ age bracket.

As previously mentioned, the increasing health concerns within this age bracket results in a decreased percentage of smokers. As for those in the medical field, it is believed that their higher education medicallink.com.au • 25

• THE MEDICAL LINK

levels, including their medical awareness of tobacco-related illnesses is the major deterrent to smoking. Interestingly, those within the engineering had the highest percentage of smokers, followed by those in the hospitality industry, 40% and 31% respectively. Stress seemed to be the major driver of smoking within the engineering and hospitality fields. Over 80% of smokers in the engineering field selected stress as the primary reason for smoking. This points towards the possibility that an occupation within the engineering field in Western Australia is stressful and/or other environmental factors contribute to making this occupation stressful. Overall, these results were consistent with a previous studies showing that those within hospitality, construction and mining had the highest rate of smoking; while those in medical and educational services had lower rates of smoking. [28] Also, despite

26 • Issue 146

the fact that engineering and hospitality have very educated professionals, they are obviously not as deeply informed about health issues as their medical counterparts. So these two professions, have the strange combination of factors where they can afford smoking and they are not as educated in their health as those in the medical profession. With those combinations they can smoke more than their medical profession counterparts.

Individuals that smoked more than 20 cigarettes per day are classified as heavy smokers, whereas those that smoked less than 20 cigarettes per day are classified as light smokers. As depicted in Table 2, 42% of the total smokers, a significant proportion, are heavy smokers. These individuals are at increased risk of tobacco-related illness and tend to have shorter life expectancy. The percentage of heavy smokers was less than that of light smok-

ers, 42% and 58% respectively; and was anticipated because the global decreasing trend of smoking was likely to result in a decreased amount of smoking overall.

By stratifying for educational attainment amongst the heavy smokers, Table 5, with increasing educational levels, from high school, vocational training (tafe) to university, the percentage of heavy smokers decreases, 56%, 25% and 0% respectively; again, supporting the strong inverse association between education and smoking status.

Why individuals started smoking, why some still smoke, and why others quit will help us understand smoking habits within the Western Australia population. The primary reason individuals started smoking, Table 3, was shown to be peer pressure. Peer pressure is commonplace within the younger population and therefore smoking prevention strategies should be aiming to reach young children during adolescence. For those that do take up smoking, some quit along the way. To avoid future health conditions was the primary reason participants quit smoking and was an expected finding supported by previous studies. [29] We know that as individuals age, the likelihood to quit smoking due to health concerns increases and this correlates well with the age groups in this study, as majority of the sample is 40 years and older. Perhaps devising more effective strategies to educate the population about the future health related risk of smoking could help reduce the number of smokers. There were other reasons for quitting, family/partner wanting them to stop was another a common finding and demonstrates the power that family members have in supporting and guiding an individual through the process of quitting smoking. For those that continued smoking, Table 2, stress was the dominant factor making up 79% of the sample size. This was an expected result; the general stresses of life and occupation can keep individuals smoking; even students continue smoking due to poor educational performance and the surrounding stresses. Therefore, smoking preventative and cessation strategies should also find methods to educate people about stress and other coping methods for managing stress. This supports the finds in a previous study, showing the positive effect anger and stress coping skills have on smoking cessation. [30]

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Limitations/Constraints

T

here were some limitations in this study including, 1) A prize was awarded for participation and therefore there is a chance that participants would falsify information, only to enter the prize draw; 2) The survey was both conducted online and via hardcopy, participants were given the privilege of completing the survey by themselves, there is no guarantee that information provided would be accurate; 3) The male population of Western Australia was underrepresented in this survey only making up about 20% of the total sample size; 4) Participants within the age groups of 18 – 29 were also underrepresented, making up approximately 9% of the total sample size; 5) The sample size of 78 was believed to be suitable for a preliminary study; however it did not allow for accurate representation of certain sub-groups within the study, such as those in the 18 – 29 age group, those with occupation of student or in the entertainment industry and those that stopped schooling after primary school.

Figure 1: Smoking Status Amongst Females

Conclusion

T

he major strength of this study is, it is likely the first study investigating the effects of education and other socioeconomic factors on smoking status, conducted in Western Australia. In conclusion, the prevalence of smoking from a Western Australia sample, was highest within 40 – 49 age group, lowest within the 50+ age group, and fits the trend described in the global smoking epidemic. The results of this study, shows that smoking is higher in females compared to males, which did not fit the global trend.

However, this could be attributed to the smaller sample size of males in this study.

This study also illustrated the well-documented inverse association between education and smoking. As education level increased the total number of smokers decreased; in addition, the percentage of heavy smokers also decreased. Participants unemployed or unable to work had the lowest rate of smoking. The primary reason participants began smoking was because of peer pressure; and continue smoking because of stress. For those that did quit smoking, to avoid futter health conditions, was the decisive factor. Based

Figure 2: Smoking Status Amongst Males

medicallink.com.au • 27

• THE MEDICAL LINK

on these findings, preventative strategies should be aimed at subgroups, with one crucial group being young adolescents.

These strategies should not only educate all subgroups about the health consequences of tobacco use, but it should also encourage further general education especially within the younger population.

Future studies should investigate the most effective smoking preventative and smoking cessation strategies; and consider using a larger sample size.

Acknowledgements The author is grateful for David D’orazio from Palm Springs Pharmacy, Warnbro, Western Australia for providing access to their client database, through which the research questionnaire was distributed.

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23. Schaap MM, Kunst AE, Leinsalu M, et al.: Female ever-smoking, education, emancipation and economic development in 19 European countries. Soc Sci Med. 2009, 68:1271-1278. 10.1016/j. socscimed.2009.01.007 24. Maralani V: Understanding the links between education and smoking. Soc Sci Res. 2014, 48:20-34. 10.1016/j.ssresearch.2014.05.007 25. McGee R, Williams S, Nada-Raja S, Olsson CA: Tobacco smoking in adolescence predicts maladaptive coping styles in adulthood. Nicotine Tob Res. 2013, 15:1971-1977. 10.1093/ntr/ntt081 26. Suhrcke M, Nieves CdP: The impact of health and health behaviours on educational outcomes in high-income countries: a review of the evidence. Edited by World Health Organization ROfE. 2011.

27. Jung Y, Oh J, Huh S, Kawachi I: The effects of employment conditions on smoking status and smoking intensity: the analysis of Korean labor & income panel 8(th)-10(th) wave. PLoS One. 2013, 8:e57109. 10.1371/journal. pone.0057109 28. Syamlal G, Mazurek JM, Hendricks SA, Jamal A: Cigarette smoking trends among U.S. working adult by industry and occupation: findings from the 2004-2012 National Health Interview Survey. Nicotine Tob Res. 2015, 17:599-606. 10.1093/ntr/ ntu185 29. McCaul KD, Hockemeyer JR, Johnson RJ, Zetocha K, Quinlan K, Glasgow RE: Motivation to quit using cigarettes: a review. Addict Behav. 2006, 31:42-56.

10.1016/j.addbeh.2005.04.004 30. Yalcin BM, Unal M, Pirdal H, Karahan TF: Effects of an anger management and stress control program on smoking cessation: a randomized controlled trial. J Am Board Fam Med. 2014, 27:645-660.

10.3122/jabfm.2014.05.140083

medicallink.com.au • 29

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