title: Implementing an anti-smoking program in rural-remote communities: challenges and strategies.
abstract: BACKGROUND
  Rural-remote communities report higher smoking rates and poorer health outcomes than that of metropolitan areas. While anti-smoking programs are an important measure for addressing smoking and improving health, little is known of the challenges faced by primary healthcare staff implementing those programs in the rural-remote setting. The aim of this study was to explore the challenges and strategies of implementing an anti-smoking program by primary healthcare staff in rural-remote Australia.
  
  
  METHODS
  Guided by a phenomenological approach, semi-structured interviews and focus groups were conducted with health service managers, case managers and general practitioners involved in program implementation in Australian rural-remote communities between 2008 and 2010.
  
  
  RESULTS
  Program implementation was reported to be challenged by limited primary and mental healthcare resources and client access to services; limited collaboration between health services; the difficulty of accessing staff training; high levels of community distress and disadvantage; the normalisation of smoking and its deleterious impact on smoking abstinence among program clients; and low morale among health staff. Strategies identified to overcome challenges included appointing tobacco-dedicated staff; improving health service collaboration, access and flexibility; providing subsidised pharmacotherapies and boosting staff morale.
  
  
  CONCLUSIONS
  Findings may assist health services to better tailor anti-smoking programs for the rural-remote setting, where smoking rates are particularly high. Catering for the unique challenges of the rural-remote setting is necessary if anti-smoking programs are to be efficacious, cost-effective and capable of improving rural-remote health outcomes.
authors.affiliation: Level 1, 230 Howick Street, Bathurst, New South Wales, Australia. julie.tall@health.nsw.gov.au.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Tall
authors.affiliation: Western New South Wales Local Health District, Bathurst, New South Wales, Australia. bronwyn.brew@newcastle.edu.au.
authors.forename: Bronwyn K
authors.initials: BK
authors.lastname: Brew
authors.affiliation: Broken Hill University Department of Rural Health, University of Sydney, Broken Hill, New South, Wales Australia. emily.saurman@health.nsw.gov.au.
authors.forename: Emily
authors.initials: E
authors.lastname: Saurman
authors.affiliation: Western New South Wales Local Health District, Bathurst, New South Wales, Australia. therese.jones@health.nsw.gov.au.
authors.forename: Therese C
authors.initials: TC
authors.lastname: Jones
mesh_terms: D001315:Australia; D005260:Female; D017144:Focus Groups; D018166:Health Care Reform; D006284:Health Plan Implementation; D006293:Health Promotion / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D011320:Primary Health Care / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D016540:Smoking Cessation / Q000379:methods* / Q000706:statistics & numerical data
keywords: Alcohol and Drug; Australia/Pacific; Continuing Professional Education; Evidence-based Care; Health Service reform; Primary Health Care