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Tobacco in Australia Facts & IssuesA comprehensive online resource

Tobacco in Australia: Facts and Issues. Fourth Edition

A comprehensive review of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria.

First edition published by ASH (Australia) Limited, Surry Hills, NSW, 1989 Second edition published by the Victorian Smoking and Health Program, Carlton South, Victoria (Quit Victoria), 1995 Third edition published by Cancer Council Victoria 2008 in electronic format only.

ISBN number: 978-0-947283-76-6

Suggested citation: Scollo, MM and Winstanley, MH. Tobacco in Australia: Facts and issues. 4th edn. Melbourne: Cancer Council Victoria; 2012. Available from www.TobaccoInAustralia.org.au OR <Author(s) of relevant chapter section>, <Name of chapter section> in Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. 4th edn. Melbourne: Cancer Council Victoria; 2012. <Last updated on (date of latest update of relevant chapter section)> Available from < url of relevant chapter or section>

Tobacco in Australia: Facts and Issues; 4th Edition updates earlier editions of the book published in 1995, 1989 and 2008. This edition is greatly expanded, comprising chapters written and reviewed by authors with expertise in each subject area. Tobacco in Australia: Facts and Issues is available online, free of charge. A hard copy version of this publication has not been produced.

This work has been produced with the objective of bringing about a reduction in death and disease caused by tobacco use. Much of it has been derived from other published sources and these should be quoted where appropriate. The text may be freely reproduced and figures and graphs (except where reproduced from other sources) may be used, giving appropriate acknowledgement to Cancer Council Victoria.

Editors and authors of this work have tried to ensure that the text is free from errors or inconsistencies. However in a resource of this size it is probable that some irregularities remain. Please notify Cancer Council Victoria if you become aware of matters in the text that require correction.

Editorial views expressed in Tobacco in Australia: Facts and Issues. Fourth Edition are those of the authors.

The update of this publication was funded by the Australian Government Department of Health and Ageing.

Cancer Council Victoria 1 Rathdowne Street Carlton VIC 3053

Project manager: Michelle Scollo Senior Policy Adviser, with assistance from Merryn Pearce, Policy and Projects Officer, Quit Victoria. Editorial advice and editing: Rosemary Moore Website design: Creative Services, Cancer Council Victoria Design and production: Jean Anselmi Communications Proofreading: Caz Garvey

Book excerpt List of chapters available at tobaccoinaustralia.org.auIntroduction

Chapter 1 Trends in the prevalence of smoking

Chapter 2 Trends in tobacco consumption

Chapter 3 The health effects of active smoking

Chapter 4 The health effects of secondhand smoke

Chapter 5 Factors influencing the uptake and prevention of smoking

Chapter 6 Addiction

Chapter 7 Smoking cessation

Chapter 8 Tobacco use among Aboriginal peoples and Torres Strait Islanders

Chapter 9 Smoking and social disadvantage

Chapter 10 The tobacco industry in Australian society

Chapter 11 Tobacco advertising and promotion

Chapter 12 The construction and labelling of Australian cigarettes

Chapter 13 The pricing and taxation of tobacco products in Australia

Chapter 14 Social marketing and public education campaigns

Chapter 15 Smokefree environments

Chapter 16 Tobacco litigation in Australia

Chapter 17 The economics of tobacco control

Chapter 18 The WHO Framework Convention on Tobacco Control

Appendix 1 Useful weblinks to tobacco resources

Tobacco in Australia Facts & Issues A comprehensive online resource tobaccoinaustralia.org.au

Chapter 8Tobacco use among Aboriginal peoples and Torres Strait Islanders

i

Date of last update: 6 Dec 2011

Chapter 8: Tobacco use among Aboriginal peoples and Torres Strait Islanders

Chapter 8

Tobacco use among Aboriginal peoples and Torres Strait Islanders

Margaret Winstanley, May 2007, updated by Anke van der Sterren and Debra Knoche, September 2011

Acknowledgements

We are grateful to Toni Mason from

Quit Victoria for her review of the

current edition of this chapter, and

to Dr Rowena Ivers, of the Graduate

School of Medicine, University of

Wollongong, for her review of the

previous edition.

Table of contents8.0 Tobacco use among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . 1

8.1 Aboriginal peoples and Torres Strait Islanders: social disadvantage, health and smoking—an overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.2 History of tobacco use among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.3 Prevalence of tobacco use among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.3.1 Geographical variations in smoking rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.3.2 Socio-economic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.3.3 Prevalence of smoking among pregnant women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

8.3.4 Prevalence of smoking among health workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.3.5 Prevalence of smoking among prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.3.6 International comparisons with other Indigenous peoples . . . . . . . . . . . . . . . 5

8.4 Smoking among Aboriginal and Torres Strait Islander children and teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.4.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.4.1.1 National surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.4.1.2 State and regional surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.4.2 Age at uptake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

8.4.3 Influences on smoking behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.5 Types of tobacco used by and levels of consumption among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.5.1 Manufactured and roll-your-own cigarettes (‘rollies’) . . . . . . . . . . . . . . . . . . . . . . 1

8.5.2 ‘Chop-chop’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.5.3 Chewing tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.5.4 Pipe and cigar use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ii Tobacco in Australia:Facts and Issues


8.6 Smoking cessation and Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.7 Morbidity and mortality caused by smoking among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.7.1 Causes of mortality and morbidity among Aboriginal

peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.7.2 Tobacco-related causes of mortality and morbidity among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . 2

8.7.3 Diseases and conditions related to smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

8.7.3.1 Circulatory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

8.7.3.2 Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.7.3.3 Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.7.3.4 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

8.7.3.5 Smoking in pregnancy, and maternal and child health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

8.7.4 Exposure to secondhand smoke and its health effects . . . . . . . . . . . . . . . . . . . . . . 7

8.8 Economic issues relating to tobacco use among Aboriginal peoples and Torres Straits Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.9 Attitudes to and beliefs about smoking among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.9.1 Why do some Aboriginal peoples and Torres Strait

Islanders smoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.9.1.1 Smoking and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.9.1.2 Smoking behaviour as a social norm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.9.1.3 Other reasons for smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.9.2 Why do some Aboriginal and Torres Strait Islander people not smoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.9.3 Awareness of the health effects of smoking and secondhand smoke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.9.4 The relative importance of smoking as an issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.10 Tobacco action initiatives targeting Aboriginal peoples and Torres Straits Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.10.1 Considering the context to develop relevant tobacco

action programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.10.2 Taking a comprehensive approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.10.3 Harm reduction approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

8.10.4 Roles of health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

8.10.5 Roles of Aboriginal health workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

8.10.6 Brief interventions and brief intervention training . . . . . . . . . . . . . . . . . . . . . . . . . . 8

8.10.7 Pharmacological assistance: nicotine replacement therapies, bupropion (Zyban) and varenicline (Champix) . . . . . . . . . . . . . . . . 9

8.10.8 Quitlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

8.10.9 Quit support groups and rehabilitation-style programs . . . . . . . . . . . . . . . . . 10

iiiChapter 8: Tobacco use among Aboriginal peoples and Torres Strait Islanders


8.10.10 Role of remote community shops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

8.10.11 Social marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

8.10.11.1 Social media and mobile phones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

8.10.12 Secondhand smoke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8.10.13 Specific sub-populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8.10.13.1 Aboriginal health workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

8.10.13.2 Youth and children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

8.10.13.3 Pregnant women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

8.10.13.4 Prisoners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

8.10.14 Broader legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

8.11 The relationship between tobacco and other drug use in Aboriginal and Torres Strait Islander communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.11.1 Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.11.2 Cannabis (marijuana, hashish, ‘ganja’ or ‘yarndi’) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.12 The tobacco industry and Indigenous communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.13 Policies for advancing tobacco control programs among Aboriginal peoples and Torres Strait Islanders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.13.1 The Framework Convention on Tobacco Control . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.13.2 The National Drug Strategy 2010–15 and the Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–09 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

8.13.3 The National Tobacco Strategy and state/territory tobacco strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

8.13.4 National Preventative Health Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

8.13.5 The Tackling Indigenous Smoking Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

iv Tobacco in Australia:Facts and Issues


Tables and figuresTable 8.3.1 Percentage (rounded) of current daily smoking among Aboriginal peoples

and Torres Strait Islanders by sex, Indigenous status and age group, 2008

Table 8.3.2 Prevalence of smoking among Aboriginal peoples and Torres Strait Islanders by sex and state or territory, Australia, 2008

Table 8.3.3 Prevalence of current daily smoking among Aboriginal peoples and Torres Strait Islanders and the non-Indigenous population aged 18 and over by a range of socio-economic indicators, 2004–05

Table 8.3.4 Prevalence rates of current smokers for Indigenous and non-Indigenous people in Canada, New Zealand, the United States and Australia

Table 8.4.1 Percentage of students self-identifying as Indigenous and non-Indigenous who have ever smoked, who are monthly smokers, current smokers, and committed smokers in each survey year between 1996–2005 (data not weighted)

Table 8.4.2 Comparison of Western Australian Indigenous (2000–02) and non-Indigenous (1993) ‘adolescents who have smoked more than just once or twice’, aged 12–16, by age and sex

Table 8.5.1 Number of cigarettes consumed per day by Aboriginal and Torres Strait Islander smokers aged 13 and over, 1994

Table 8.6.2 Smoker status among Aboriginal peoples and Torres Strait Islanders and total Australian population, by sex and age, 2004–05

Table 8.6.1 Age-standardised smoker status, Indigenous and non-Indigenous persons, 2008

Table 8.6.3 Comparison of tobacco-related behaviour modification in the last 12 months among Aboriginal peoples and Torres Strait Islanders and the general Australian population, National Drug Strategy Household Surveys 1993 and 1994

Table 8.7.1 Rate ratios of top 12 leading causes of DALYs by sex, comparing Indigenous Australian and total Australian populations, 2003

Table 8.11.1 Prevalence of smoking, alcohol consumption and other substance use among Indigenous persons aged 15 and over, Australia, 2008

1Chapter 8: Tobacco use among Aboriginal peoples and Torres Strait Islanders

Section: 8.0Date of last update: 26 March 2012

8.0

Tobacco use among Aboriginal peoples and Torres Strait Islanders Some of the information in this chapter also appears elsewhere in this publication, but because of specific interest in matters relating to tobacco use among Australia’s Aboriginal peoples and Torres Strait Islanders, material on the subject has been collected in one place to aid quick reference. Readers seeking broader discussion should also refer to other chapters.

A note on terminologyIt is recognised that the preferred term for Australia’s Indigenous peoples is Aboriginal peoples and Torres Strait Islanders, and where practical, this title has been used throughout this chapter. The term Indigenous is also used throughout, generally with the intention of reducing repetitiveness or aiding concision for the reader; where it appears, it refers to both population groups.

A note on data and statisticsThe information in this chapter on Aboriginal and Torres Strait Islander health and smoking should be understood in the context of the challenges that exist in the collection, analysis and interpretation of health data on Indigenous peoples. Data quality will be affected by issues such as: the potential under-identification of Aboriginal peoples and Torres Strait Islanders; the lack of data sets from some jurisdictions or regions, meaning that some ‘national’ data do not actually represent the entire Indigenous population; small numbers of participants; and methodologies that may not suit Indigenous people (or Indigenous people in some regions). Comparison of data sets (whether comparing data sets between Indigenous peoples, or between Indigenous and non-Indigenous peoples) is complicated by different data collection methods, and the differing definitions used (e.g. for definitions of smoking status or age groupings).

In addition, data specifically related to smoking rates among Torres Strait Islanders are only reported separately in Queensland; in other jurisdictions data relating to Aboriginal peoples and Torres Strait Islanders are reported together. While national data sets collect information on the health of Torres Strait Islanders, analyses of this data in relation to smoking are not publicly available.

2 Tobacco in Australia:Facts and Issues


8.1

Aboriginal peoples and Torres Strait Islanders: social disadvantage, health and smoking—an overviewTwo distinct Indigenous populations inhabit Australia: Aboriginal peoples and Torres Strait Islanders. Initially, Aboriginal peoples lived throughout mainland Australia and Tasmania and on many offshore islands, while Torres Strait Islanders inhabited the northernmost peak of the Australian mainland and the islands of the Torres Strait scattered between Cape York Peninsula and Papua New Guinea.1 Both groups are now less clearly defined by geography, many Torres Strait Islanders having moved to mainland Australia for economic reasons,1 and the Torres Strait region now being home to a substantial population of individuals of both Torres Strait Islander and Aboriginal origin.2 There is also enormous diversity among different Aboriginal and Torres Strait Islander communities across the country—diversity in culture, language and the ways that these communities experienced colonisation.1 The experiences of colonisation have shaped the ongoing socio-economic disadvantage, poorer health status, and, to some extent, the patterns of tobacco use within these communities. While native tobaccos were used in many Aboriginal and Torres Strait Islander communities prior to colonisation, these have largely been replaced by commercially available tobacco and cigarettes, and the pre-contact practices around production and consumption of tobacco have been lost (see Section 8.2).

Combined, Aboriginal peoples and Torres Strait Islanders make up 2.5% of the Australian population, numbering an estimated 517 043 in 2006.3 Those of Aboriginal origin account for 90% of the total Indigenous population, and Torres Strait Islanders comprise 6% of the total Indigenous population. The remaining 4% are of combined Aboriginal and Torres Strait Islander descent.3 The majority (75%) of Aboriginal peoples and Torres Strait Islanders live in non-remote areas, although proportionately more Indigenous than non-Indigenous people live in remote or very remote locations (25% versus 2%).4 More than half of all Indigenous people reside in New South Wales and Queensland combined (30% and 28% respectively). The Northern Territory is home to 12% of the Indigenous population, but has the highest proportion of residents of Aboriginal and Torres Strait Island origin (30%). In all other states and territories, the combined Indigenous population comprises less than 4% of the total resident population.3

From a population perspective and according to a broad range of social and economic indicators, Aboriginal peoples and Torres Strait Islanders are by far the most disadvantaged sub-group in the Australian population. The median income of Indigenous households is just more than half that (56%) of non-Indigenous households.4 Indigenous Australians are more likely to occupy overcrowded or otherwise substandard housing, to be unemployed, to attain lower levels of formal education and to have poorer access to facilities and services than other Australians.4,5 Members of these communities are also more likely to meet with violence, to come into contact with the criminal justice system as victims or offenders, and to be over-represented in the prison system.4,5 Contributing to and compounding these adverse outcomes are the ongoing traumas of dispossession, cultural dislocation, racism and separation of families experienced by many individuals and communities.1,6,7

Aboriginal peoples and Torres Strait Islanders also have poorer health outcomes than the rest of the Australian population as a whole.3,4 Much of the burden of ill-health is attributable to chronic diseases, including diabetes, heart and respiratory conditions. For the period 2005–07, life expectancy at birth for members of Aboriginal and Torres Strait Islander communities was estimated to be 67.2 years for males and 72.9 years for females, compared to 78.7 years for males and 82.6 years for females for all Australians.3 This pattern of ill-health is not unique to Australia’s Indigenous peoples. Indigenous populations in New Zealand, the United States and Canada have also experienced significantly higher mortality rates than the overall populations in these countries. However, the reductions in health inequality seen in these countries since the 1970s are not apparent in Australia.8

The poorer health outcomes for Aboriginal peoples and Torres Strait Islanders are partly attributable to the high rates of tobacco use in these communities. Smoking accounts for 20% of Indigenous deaths and 12.1% of the burden of disease, more than any other risk factor.9 Tobacco is a causal, contributing or complicating factor in many of the diseases that contribute most to Indigenous mortality and morbidity, including circulatory diseases, cancer, respiratory diseases, diabetes and pregnancy-related conditions (see Section 8.7). Smoking also has an economic and social impact on Aboriginal and Torres Strait Islander communities (see Section 8.8).



Forty-seven per cent of Indigenous people aged 15 and over are current smokers,10 although there is considerable variation in tobacco use rates by location, age group and gender (see Section 8.3). Indigenous people are more than twice as likely as non-Indigenous people to be smokers, and this ‘gap’ has widened since the 1980s. Smoking rates in the broader Australian community have been falling, while Indigenous smoking rates have been relatively stable until recently. Between 2002 and 2008, there has been a significant decline in Indigenous smoking rates,11 although the ‘gap’ in smoking rates is still large. Public health activities in smoking prevention and cessation that have been so successful in the general Australian community (such as national advertising campaigns, taxation, and smoke-free legislation) appear to have had limited impact on smoking rates in Aboriginal and Torres Strait Islander communities.

Individuals and organisations across multiple sectors and from around the country have been working to reduce smoking rates in Aboriginal and Torres Strait Islander communities for the past twenty years or more. Their efforts have been hampered by poor and unsustained funding, and by the complex challenges facing the health system in delivering health care to Indigenous communities more generally. These challenges include: the capacities of health services and workers; inappropriate development or targeting of programs and resources; insufficient involvement of Indigenous communities; and the lack of strategic coordinated action (see Section 8.10). In addition, addressing tobacco use in Indigenous communities is difficult simply because the reasons to continue smoking are so strong, sometimes too strong for individuals to overcome. Interrelated socio-economic factors (such as income, employment, education and housing), as well as other social factors (such as incarceration, removal from family and racism) are important determinants of tobacco use in Aboriginal and Torres Strait Islander communities (see Section 8.3). Stress associated with poor health and socio-economic conditions, as well as from family and community relationships, work expectations, or from racism and marginalisation, contributes to maintaining high smoking rates and causing relapse (see Sections 8.6 and 8.9).

However, socio-economic factors alone are not sufficient to drive high rates of smoking in Indigenous communities; there are also unique social and cultural factors at play (see Sections 8.6, 8.9 and 8.10). Many people living in Aboriginal and Torres Strait Islander communities are exposed to smoking behaviour in some way; this reinforces the behaviour for smokers and encourages smoking uptake among non-smokers (particularly children). The normalisation of tobacco use is reinforced by the communal nature of smoking, and the social obligations to exchange and share tobacco. Smoking is, therefore, a means of reinforcing social relationships and maintaining social cohesion. In this cultural context, extended families are important in the uptake and maintenance of smoking, as well as being influential in smoking cessation.

Although many individuals and organisations have been implementing tobacco action activities, most have not been evaluated due to a lack of funds or expertise, and the small scale of the activities. Evidence as to what works in tobacco action in Aboriginal and Torres Strait Islander communities is, therefore, limited. Tobacco action programs in these communities are currently designed based largely on what is known about the efficacy of tobacco-control activities in the general Australian community. It is clear, however, that Indigenous tobacco action programs must also incorporate approaches that take into account the socio-economic realities of peoples’ lives and the unique social and cultural contexts, as well as considering how to overcome challenges with the healthcare delivery system (see Section 8.10). Over recent years, there has been a significant commitment to a strategic approach to Indigenous tobacco control with accompanying funding, and over the coming years more evidence of best practice in Indigenous tobacco action will become available as new programs are implemented and evaluated.

Comprehensive, multi-component and community-based tobacco action programs are thought to be the most effective, and many such programs are being developed and implemented in Aboriginal and Torres Strait Islander communities across Australia (see Section 8.10). These programs include a mix of individual-, family-, and community-directed activities to ensure maximum coverage and benefit to smokers and non-smokers. Many programs are also being implemented that include components directed towards specific important target groups: young people, pregnant women, Aboriginal health workers and prison inmates.

Addressing Indigenous inequalities in smoking and health is a national priority at both the national and state/territory levels. The Council of Australian Governments has committed to ‘closing the gap’ in Indigenous health outcomes, and has set ambitious targets to reduce smoking rates and smoking-related harm. Each jurisdiction has developed implementation plans that are closely related to the strategies and targets articulated in their tobacco strategies or action plans (see Section 8.13).



References1. Aboriginal and Torres Strait Islander Commission. As a matter of fact. Answering the myths and misconceptions about Indigenous Australians. Canberra: Commonwealth of Australia,

1998.

2. National Drug Strategy Unit. Ministerial Council on Drug Strategy. Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009. Canberra: Australian Government Department of Health and Ageing, 2006. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/545C92F95DF8C76ACA257162000DA780/$File/indigenous-background.pdf

3. Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2010 Canberra: ABS, 2010. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/4704.0

4. Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2008. cat. no. AIHW 21. Canberra: ABS, 2008. Available from: http://abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4704.02008?OpenDocument

5. Australian Government Productivity Commission. Overcoming Indigenous disadvantage: key indicators 2009. Canberra: AGPC, 2009. Available from: http://www.pc.gov.au/gsp/reports/indigenous/keyindicators2009

6. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander Tobacco Control Project final report. Canberra, Australia: National Aboriginal Community Controlled Organisations, 2002. Available from: http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf

7. Ivers R. Indigenous tobacco—a literature review. Darwin, Australia: Menzies School of Health Research and the Co-operative Research Centre for Aboriginal and Tropical Health, 2001. Available from: http://www.lowitja.org.au/files/crcah_docs/Indigenous_Australians_and_Tobacco.pdf

8. Ring I and Firman D. Reducing indigenous mortality in Australia: lessons from other countries. Medical Journal of Australia 1998;169:528-33. Available from: http://www.mja.com.au/public/issues/nov16/ring/ring.html#bodydrop0

9. Vos T, Barker B, Stanley L and Lopez A. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland, 2007. Available from: http://www.uq.edu.au/bodce/index.html?page=68411

10. Australian Bureau of Statistics. 4714.0 National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4714.02008?OpenDocument

11. Thomas D. National trends in Aboriginal and Torres Strait Islander smoking and quitting. Australia and New Zealand Journal of Public Health 2012;36(2):24-9. Available from: http://www.wiley.com/bw/journal.asp?ref=1326-0200

http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/545C92F95DF8C76ACA257162000DA780


indigenous-background.pdf

http://www.abs.gov.au/ausstats/abs

http://abs.gov.au/AUSSTATS/abs

http://www.pc.gov.au/gsp/reports/indigenous/keyindicators2009


http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf

http://www.lowitja.org.au/files/crcah_docs/Indigenous_Australians_and_Tobacco.pdf

http://www.mja.com.au/public/issues/nov16/ring/ring.html

http://www.mja.com.au/public/issues/nov16/ring/ring.html

http://www.uq.edu.au/bodce/index.html?page=68411

http://www.abs.gov.au/AUSSTATS/abs

http://www.wiley.com/bw/journal.asp?ref=1326-0200




8.2

History of tobacco use among Aboriginal peoples and Torres Strait IslandersThis section draws substantially on a range of secondary articles and reviews,1–11 which together provide an extensive reference list of primary resources, including accounts of tobacco use provided by Indigenous peoples, early European settlers and anthropologists. Those pursuing further information are referred to these publications in the first instance.

Australian natural flora includes several plants containing nicotine, some of which have traditionally been harvested, prepared, traded and chewed by Indigenous peoples across much of Australia. The most potent of these is ‘pituri,’ made from leaves of the shrub Duboisia hopwoodii, which has a nicotine content of up to 8%,6 much greater than that found in manufactured cigarettes.5,6 Although Duboisia hopwoodii naturally occurs over much of southern and western Australia, most pituri was prepared in south-western Queensland, and from there distributed almost as far north as the Gulf of Carpentaria, south to Lake Eyre in South Australia, east to the mid-region of Queensland, and west to the area where Alice Springs is now located, an area covering more than half a million square kilometres.4,5 It is also believed that a second centre for pituri processing was located somewhere in Western Australia, but little is known of it.4 It remains unclear exactly why pituri production was such a localised behaviour, when it was considered such a valuable commodity and Duboisia hopwoodii is not an especially rare plant. One theory is that remote end-users of the processed product may not have recognised the association between pituri and the shrub, but it is now considered more likely that the leaves from plants growing in the south-west of Queensland (and possibly those from the Western Australia centre as well) were favoured because they contained nicotine in a less immediately toxic form.4,5

Other plants traditionally used for chewing include the nicotine-containing species Nicotania gossei, Nicotania suaveolens, Nicotania excelsior and Nicotania ingulba.6 These ‘bush tobaccos’ were chewed by men, women and children, and, like pituri, were widely traded over long distances.1,8 Bush tobaccos are still used and traded in some regions3–6 (see Section 8.5.3). Over time, terminology has altered, and in some regions bush tobaccos are now collectively referred to as pituri.1,3,5,6,8

Pituri was prepared by drying selected leaf and stems of the Duboisia hopwoodii, often in sand ovens,5 then packing the product into specially woven bags, ready for trading.4 Pituri was produced and traded in such considerable volumes that it is probable that those who harvested it also used techniques to maximise cropping.4 Early reports show that knowledge regarding processing had a sacred ritual significance and was vested in specific groups or clans, and that usage was probably restricted to older males.4,5 Prior to chewing, pituri4 (and other bush tobaccos, such as Nicotania spp.)6,1 would be mixed with alkaline wood ash, which facilitated the release of nicotine from the leaf and enhanced its absorption through the lining of the mouth. This process has been likened to the combining of betel with lime prior to chewing,4 as practised throughout much of the Asian subcontinent.12

The mood-enhancing effects of nicotine lent the offering of pituri significance as an overture of friendship, and in some ceremonies the sharing of pituri both symbolised and facilitated social bonding.4,6 It also fulfilled the practical purposes of suppressing appetite, providing sustenance on long journeys,4,7 and, in larger quantities, serving as a painkiller.4,6 Pituri was the most highly valued commodity in circulation; it was so important that it has been described as the ‘gold standard’6 of Indigenous trading. Although it is likely that at least a proportion of users were addicted to it,4,6 because its usage was strictly controlled,6 it is probable that quantities of pituri used beyond the immediate localities where the plant was to be found were low.9 Pituri would remain an important social and trading commodity until the early twentieth century,4 but its traditional methods of preparation and constraints on use were lost in the decades following European settlement.4,5

Tobacco, and the practice of smoking, first reached the shores of northern Australia at the beginning of the eighteenth century, when Macassan fishermen sailed from the Indonesian island now known as Sulawesi in search of pearls and trepang (a seafood delicacy intended for export to China). The trade was important to the Macassans. About a thousand men would make the voyage each year and stay in the region for several months at a time, until operations were abandoned two centuries later in the early 1900s.8



The Macassans acknowledged Indigenous ownership of the land and offered pipes, tobacco and other valued goods as tribute to local populations and in return for access to coastal waters and camping places ranging between the Kimberley to the Gulf of Carpentaria.6 The Macassan method of smoking, with a characteristic long-stemmed pipe formed from a crab claw, a hollow root or a reed,7 became part of Indigenous social and ceremonial life in these areas,8 and is still in use in the East Arnhem region.3 Macassan goods, including tobacco and pipes, were prized as trade items by the local population and were borne far inland.6 However, given the sporadic nature of supply from the Macassan fisherman, it is unlikely that exposure to the new tobacco resulted in ongoing addiction.9

Tobacco smoking was also introduced into Cape York and the Torres Strait region, although it is not clear by whom, and according to early eye-witness accounts, Torres Strait Islanders grew plants that contained nicotine and smoked pipes made of bamboo.13 While it cannot be said for sure just how widespread nicotine usage became,8 it is likely that people in south-eastern Australia did not have access to nicotine before European contact.14

With the arrival of the First Fleet in 1788, British patterns of tobacco usage were introduced to Australia. Tobacco was commonly used by all echelons of colonial society; officers and other socially elevated males using snuff and later cigars; the marines and convicts favoured clay pipes.6

Tobacco was often presented in early encounters between the Europeans and Indigenous people as a token of goodwill and conciliation.8 The introduced tobaccos and pipes soon became popular and widely sought after by Indigenous communities, whether or not they had been users of bush tobaccos or pituri,8 and were highly valued, along with other introduced commodities such as blankets, flour and sugar. The Indigenous desire for tobacco and other wares was quickly recognised by the European settlers, who offered them in exchange for labour, goods and services, and hoped that such inducements would lead the Indigenous occupants of the land to forego their traditional lifestyle and become compliant participants in the settlement’s activities.6 For their part, the Indigenous population actively set about obtaining tobacco and other prized goods from their new sources. Communities negotiated and bargained, exacting tobacco and supplies as just consideration for use of the land and resources, in accordance with Indigenous tradition.6 However the colonial intention to instil a Western work ethic, with its keystones of regular habits, subordination of servant to master, economic incentives and accumulation of wealth and goods, remained contrary to the Indigenous world view.6

That said, tobacco trade in the early days of colonisation has been interpreted as a process of ‘mutual exploitation’, both parties for the most part initially deriving satisfaction from their side of the transaction.6 If the new settlers had the advantage of controlling tobacco supplies, the local inhabitants equally had the option of providing or withholding information, labour and other markers of cooperation vital to the Europeans. Over time, however, this balance would firmly come to favour the new settlers.

Over the following years, usage—and hence addiction to nicotine—permeated vast tracts of the continent, with the expansion of European outposts through explorers, missionaries, pastoralists, cattle farmers, miners, fishermen and anthropologists.7,8,14 In contrast to the European population, tobacco was used by Indigenous men, women and children.10 Tobacco was also a trade item for some Indigenous groups, allowing the product to penetrate distant regions of Australia long before direct white contact was made.6

The development of tobacco dependency among Indigenous people was variously interpreted by the colonists as a ‘civilising’ or a ‘taming’ influence: civilising because it could aid discourse and engender goodwill, and taming because it had the capacity to produce a cheap labour force prepared to work in return for tobacco.6,15 Widespread nicotine addiction made the Indigenous populations vulnerable to manipulation by the settlers, who could make provision of tobacco dependent upon compliance.8 At least one Victorian squatter deliberately fostered tobacco use among local Indigenous people, enabling him to secure their ongoing services in return for small amounts of tobacco.7 Tobacco became standard payment in kind. During the 1800s and the early decades of last century, Aboriginal peoples and Torres Strait Islanders worked in often brutal circumstances for the cattle and pastoral industries, on sugar plantations, in road gangs, and in the pearl shell and trepang trade, remunerated in full or in part with tobacco.6,11 And not only labour was paid for with tobacco. Material goods, such as artefacts and ceremonial objects, and intellectual property, including language, local knowledge, oral history and cultural heritage, were acquired by collectors, anthropologists and other researchers in return for tobacco.6

The decades following European colonisation saw gradual movement of communities of Indigenous peoples into white settlements, in response to a range of influences, including government policies and other prevailing circumstances, and desire for a range of provisions, including tobacco.6,11 This process has been described as a



form of ‘accidental migration’, whereby once the relocation occurred, reversal became increasingly difficult as intimate knowledge of homelands faded, and dependency and habit bred a new way of life that became normal to successive generations.6,11 As more people moved to missions or settlements, traditional ways of living were less viable for those left behind. The drift to white settlement became difficult to resist.6 Populations that had survived for thousands of years virtually without external intervention were soon to become dependent on European settlement, as a result of which many were to suffer marginalisation and segregation, and shift their connections with their lands and traditional ways of living, as well as their languages, histories and cultures.16

On pastoral mission stations, whether run by churches, the government or privately, tobacco formed an important part of rations, and was provided with the expectation of compliance in a regimen of work (and, in the Christian missions, participation in religious activities as well).6 Tobacco rations undoubtedly initiated and reinforced tobacco use among many individuals, and although the practice of including tobacco in rations declined from the 1940s onwards, it did not stop completely on cattle stations until the late 1960s.9 Interestingly, one researcher has observed that in some remote communities, tobacco is still used as an ‘ice breaker’ by some health professionals as well as anthropologists and lawyers to facilitate their work.9

Pre-existing traditions of nicotine use and barter among much of the Aboriginal and Torres Strait Island population predisposed them to ready acceptance of European tobacco,6 but the process of colonisation was to change Indigenous patterns of tobacco use for ever. The cultural mores relating to traditional tobacco use vanished as the ‘pituri clans’, the custodians of ritual and knowledge, lost their way of life or died out,5 and ready-processed tobacco became widely available in ample quantities.6 The relentless process of more than 200 years of colonisation has done much to reinforce smoking in these populations.17 The effects of ill-conceived social control policies, such as relocation of people from traditional homelands and enforced separation of children and families, and the cumulative burdens of racial prejudice and socio-economic disadvantage, have contributed to continuing socio-economic disadvantage and lower health status for Aboriginal peoples and Torres Strait Islanders as compared to non-Indigenous Australians.17,18 The connection between low socio-economic status and tobacco use is well established, but in the case of Aboriginal peoples and Torres Strait Islanders it is reinforced by its origins in early tradition and ritual, its continued ceremonial uses in some communities,14 and its enduring significance as a symbol of sharing, friendship and solidarity.8

Socio-cultural aspects of modern day tobacco use are also discussed in Section 8.9, and socio-economic issues are discussed in sections 8.3 and 8.8.



References1. Ratsch A, Steadman KJ and Bogossian F. The pituri story: a review of the historical literature surrounding traditional Australian Aboriginal use of nicotine in Central Australia. Journal of

Ethnobiology and Ethnomedicine 2010;6:26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20831827

2. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander Tobacco Control Project final report. Canberra: National Aboriginal Community Controlled Organisations, 2002. Available from: http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf


4. Watson P, Luanratana O and Griffin W. The ethnopharmacology of pituri. Journal of Ethnopharmacology 1983;8:303-11.

5. Low T. Pituri: tracing the trade routes of an indigenous intoxicant. Australian Natural History 1987;22:257-60.

6. Brady M and Long J. Mutual exploitation? Aboriginal Australian encounters with Europeans, Southeast Asians, and tobacco. In Jankowiak, W and Bradburd, D, eds, Drugs, labor and colonial expansion. Tuscon: The University of Arizona Press, 2003. Available from: http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/Brady_2003.pdf

7. Walker R. Tobacco smoking in Australia, 1788–1914. Historical Studies 1980;19:267–85.

8. Brady M. Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people. Australian and New Zealand Journal of Public Health 2002;26(2):116–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12054329

9. Ivers R. Tobacco addiction and the process of colonisation. Australian and New Zealand Journal of Public Health 2002;26:280-1.

10. Walker R. Under fire. A history of tobacco smoking in Australia. Melbourne, Australia: Melbourne University Press, 1984.

11. Read P and Japaljarri E. The price of tobacco: the journey of the Warlmala to Wave Hill, 1928. Aboriginal History 1978;2(140-8)

12. World Health Organization and International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 85: Betel-quid and areca-nut chewing and some areca-nut-derived nitrosamines. Summary of data reported and evaluation. Lyon, France: IARC, 2004. Available from: http://monographs.iarc.fr/ENG/Mongraphs/vol85/volume85.pdf

13. McNiven IJ. Inclusions, exclusions and transitions: Torres Strait Islander constructed landscapes over the past 4000 years, northeast Australia. The Holocene 2008;18(3):449–62. Available from: http://hol.sagepub.com/content/18/3/449.abstract

14. Briggs VL, Lindorff KJ and Ivers RG. Aboriginal and Torres Strait Islander Australians and tobacco. Tobacco Control 2003;12(suppl. 2):ii5-8. Available from: http://tobaccocontrol.bmj.com/cgi/content/extract/12/suppl_2/ii5

15. Angelo A. Kimberleys and North-West goldfields. Early Days. Early Days: Journal of the Royal Western Australian Historical Society 1948;3(10):38–45. Available from: http://histwest.org.au/?page=publications

16. Vickery J, Faulkhead S, Adams K and Clarke A. Indigenous insights into oral history, social determinants, and decolonisation. In Anderson, I, Baum, F, and Bentley, M, eds, Beyond bandaids: exploring the underlying social determinants of Aboriginal health. Papers from the Social Determinants of Aboriginal Health Workshop, Adelaide July 2004. Darwin, Australia: Cooperative Research Centre for Aboriginal Health, 2007. Available from: http://www.crcah.org.au/publications/downloads/Beyond-Bandaids-CH2.pdf

17. Flick B. Drugs of opulence and drugs of dispossession. Aboriginal and Islander Health Worker Journal 1998;22(4):7-9.

18. Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2010 Canberra: ABS, 2010, [viewed September 2010]. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/4704.0

http://www.ncbi.nlm.nih.gov/pubmed/20831827



http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/Brady_2003.pdf


http://monographs.iarc.fr/ENG/Mongraphs/vol85/volume85.pdf

http://monographs.iarc.fr/ENG/Mongraphs/vol85/volume85.pdf

http://hol.sagepub.com/content/18/3/449.abstract

http://tobaccocontrol.bmj.com/cgi/content/extract/12/suppl_2/ii5


http://histwest.org.au/?page=publications

http://histwest.org.au/?page=publications

http://www.crcah.org.au/publications/downloads/Beyond-Bandaids-CH2.pdf




8.3

Prevalence of tobacco use among Aboriginal peoples and Torres Strait IslandersTobacco use is widespread among Aboriginal and Torres Strait Islander populations,1,2 although prevalence varies regionally and from community to community across the country. The first major national study measuring smoking prevalence in the Indigenous population was the National Aboriginal and Torres Strait Islander Survey of 1994,3 subsequently updated with the National Aboriginal and Torres Strait Islander Social Surveys of 2002 and 2008.4,1 National baseline data on drug use among urban Aboriginal peoples and Torres Strait Islanders were also collected in 1994 as a supplement to the National Drug Strategy Household Survey.5 Successive National Drug Strategy Household Survey reports in 1998,6 2001,7 2004,8 and 20079 have included data on tobacco use among these populations. The National Health Surveys of 199510 and 200111 also provide data sets, and the National Aboriginal and Torres Strait Islander Health Survey for 2004‒05 has been added to this series, enlarging on the Indigenous component of the earlier National Health Survey reports.2 Most of the data presented in this section come from the National Aboriginal and Torres Strait Islander Social Surveys of 20024 and 20081 and the National Aboriginal and Torres Strait Islander Health Survey for 2004‒05;2 these surveys have comparatively large sample sizes.

Table 8.3.1 shows rates for Aboriginal and Torres Strait Islander current daily smokers, by sex, Indigenous status and age group, for 2008.12 When compared to the overall Australian population, Aboriginal peoples and Torres Strait Islanders have a substantially higher prevalence of smoking for all age groups among both men and women. Forty-seven per cent of the combined Aboriginal and Torres Strait Islander population aged 15 and over are current smokersi.1 After adjusting for differences in age structure, Aboriginal peoples and Torres Strait Islanders aged 15 and over are more than twice as likely as non-Indigenous Australians to be current smokers. Aboriginal peoples and Torres Strait Islanders aged 15 and over are also less likely to have never smoked compared to non-Indigenous Australians (31% compared to 52%).1 A comparative analysis of data from the Aboriginal and Torres Strait Islander national surveys in 1994, 2002 and 2004 shows that, in Queensland, Torres Strait Islander men and women had lower smoking rates in each of these surveys than Aboriginal people (though not statistically significant).13

It is commonly claimed that smoking rates for Aboriginal peoples and Torres Strait Islanders have remained virtually unchanged between 1994 and 2004, as data from national surveys between these times appear to report similar smoking prevalence rates. However, these surveys have differed in the way they defined smoking status and in the age groups surveyed. A re-analysis of data from these national surveys actually shows a decline in prevalence of ‘current smokers’ by 2.4% over this time period for Aboriginal peoples and Torres Strait Islanders aged 18 and over: from 54.5% in 1994 to 53.5% in 2002 to 52.1% in 2004.13 Although this decline is statistically not significant, these figures may indicate an important trend.13 Further analysis with the inclusion of data from the

i The National Drug Strategy Household Survey for 2004, as in previous years, reports on a small Indigenous sample. The prevalence of smoking reported in the 1994, 1998 and 2001 surveys was similar to that of the other national surveys discussed above. However the surveys for 2004 and 2007 returned much lower population prevalence figures of 39% (2004) and 34% (2007), down from 49% in 2001. Given the consistently higher prevalence data published by other, larger national surveys, it is likely that the National Drug Strategy Household Survey figure is an outlier. This is probably due to differences in sampling between the 2001 and the 2004 and 2007 surveys, and to smaller proportionate samples of Indigenous people with each survey. It is known that there is considerable variation in smoking rates between various Indigenous communities, which if not sampled in a comparable manner between surveys, could be expected to skew results.

Table 8.3.1 Percentage (rounded) of current daily smoking* among Aboriginal peoples and Torres Strait Islanders by sex, Indigenous status and age group, 2008

Indigenous status

Age group15–24 25–34 35–4 45–54 55+

MalesIndigenous 39 56 56 48 33Non-Indigenous 16 29 26 22 12

FemalesIndigenous 40 50 47 46 31Non-Indigenous 14 19 20 20 11

* Current daily smokers are those who smoke one or more cigarettes (either manufactured or roll-your-own), cigars or pipes per day, on average. Chewing tobacco and smoking of substances other than tobacco are excluded.14

Sources: ABS 201012 using data from the National Aboriginal and Torres Strait Islander Social Survey 2008 and the 2007 –08 National Health Survey


Section: 8.3.1Date of last update: 26 March 2012

2008 National Aboriginal and Torres Strait Islander Social Surveys reports a significant decline between 1994 and 2008 in smoking rates among Indigenous men in both remote and non-remote areas: from 58.5% in 1994 to 52.6% in 2008, an absolute decrease of 0.4% per year. Female smoking rates fell from 51.0% to 47.4%; for women in non-remote areas, smoking rates fell by 0.5% per year (from 53.5% in 1994 to 46.3% in 2008), but for women in remote areas, smoking rates rose by 0.4% per year (from 45.0% to 50.4%).15 A comparison between the prevalence rates of current daily smokers aged 15 and over reported in the 2002 and 2008 National Aboriginal and Torres Strait Islander Social Surveys also shows a significant fall from 49% in 2002 to 45% in 2008.12

The considerable impact of smoking on the health of Aboriginal peoples and Torres Strait Islanders is detailed in Section 8.7. For discussion about recommended tobacco-control interventions designed to meet the needs of these population groups, refer to sections 8.10 and 8.13.

8.3.1

Geographical variations in smoking ratesWhile the figures in the above tables provide a broad overview of smoking prevalence among Aboriginal peoples and Torres Strait Islanders, it is important to note that patterns of smoking are not uniform throughout Aboriginal and Torres Strait Islander communities. Data from the 2008 National Aboriginal and Torres Strait Islander Social Survey shows that Aboriginal and Torres Strait Islander people living in non-remote areas are less likely to smoke than those living in remote areas (43% compared with 49%),1and that this is true for both males and females.15 Smoking rates have been falling between 1994 and 2008 for remote and non-remote men and non-remote women, but have been rising for remote women.15 There are also differences in prevalence rates among the states and territories (Table 8.3.2). Apart from a significant increase in female smoking in the Northern Territory, smoking rates among males and females decreased in all jurisdictions between 1994 and 2008.15 There are also variations in prevalence by age, gender and location within these jurisdictions. For example in the Northern Territory in 2008 (National Aboriginal and Torres Strait Islander Social Survey data), the highest proportion of male smokers were aged between 25 and 44 years (67.5%), while the highest proportion of female smokers were among those aged 18–24 years (60.2%). Smoking was more common among men living in remote areas (63.9%) than non-remote areas (44.0%). The opposite is true for women, with higher rates in non-remote areas (57.0%) than remote areas (48.2%).16

More striking, however, are the variations in smoking behaviour between smaller regions and individual communities. The National Aboriginal and Torres Strait Islander Survey from 1994 examined prevalence of smoking as defined by Aboriginal and Torres Strait Islander Commission region,i and found a large variation between regions. While later national surveys have not been able to provide regional or local estimates of smoking prevalence rates for Aboriginal and Torres Strait Islander people, other regional and community-specific surveys have also demonstrated a wide variability in smoking prevalence. For example, a survey of Aboriginal and Torres Strait Islander women aged 15–34 years in 23 communities in far north Queensland found a smoking rate of 62%,18 and studies have confirmed higher rates of smoking in the Top End of the Northern Territory than for the Indigenous population as a whole.19–22 The most recent of these studies found smoking rates of 76%21 and 70%22 in Top End communities. A 1993–97 study in nine Torres Strait Islander communities in far north Queensland found an overall smoking prevalence rate of 45%, which is lower than the overall Indigenous smoking rate, but a much higher prevalence of smoking (63%) among men aged between 15 and 34.23

i The 36 Aboriginal and Torres Strait Islander Commission regions were legally prescribed areas for the purposes of administration by the now superseded Aboriginal and Torres Strait Islander Commission and the Torres Strait Regional Authority.17

Table 8.3.2 Prevalence of smoking among Aboriginal peoples and Torres Strait Islanders by sex and state or territory, Australia, 2008

State/Territory Current smokers (%)Male Female

New South Wales 49.7 52.0Victoria 49.5 49.8Queensland 55.4 40.9South Australia 52.4 50.4Western Australia 49.2 46.3Northern Territory 60.0 50.2

Source: Thomas 201215 using data from the National Aboriginal and Torres Strait Islander Social Survey 2008



Readers interested in examining earlier regional prevalence surveys are referred in the first instance to the comprehensive literature review by Ivers,24 which provides a summary of research undertaken up until 1999.

8.3.2

Socio-economic factorsSocio-economic factors are strongly related to smoking behaviour throughout the general Australian population (see Chapter 1, Section 1.5 for further discussion).

Aboriginal peoples and Torres Strait Islanders are still significantly more likely than non-Indigenous people to be disadvantaged, in measures such as educational attainment, employment, income and home ownership,1,12 (although there have been some improvements in socio-economic outcomes since the National Aboriginal and Torres Strait Islander Survey of 1994).3 For example, in 2006, adjusting for size and composition of the household, average gross household income for Indigenous people was $362 per week, 56% of that of non-Indigenous people ($642). The median weekly individual income of Indigenous Australians aged 15 years and over was also just over half that of non-Indigenous persons ($278 compared to $473).25

Moreover, individuals from Aboriginal and Torres Strait Islander backgrounds are over-represented among those Australians who experience mental illness (as evidenced by self-reported levels of psychological distress, higher rates of hospitalisation for mental illness, and death and injury through suicide and intentional injury), homelessness and exposure to the criminal justice system as offenders (with imprisonment at 14 times the rate of non-Indigenous people and juvenile detention at 23 times the rate for non-Indigenous youth).12,25 Each of these factors is associated with a greater likelihood of smoking (see Chapter 1, Section 1.8). The overall higher degree of disadvantage experienced by Aboriginal peoples and Torres Strait Islanders is likely to be a major contributor to their higher than average prevalence of smoking.

Smoking rates also vary within the Aboriginal and Torres Straits Islander populations according to socio-economic factors, as they do in the general Australian population. Analyses of the associations between various socio-economic factors and smoking status among Aboriginal peoples and Torres Strait Islanders have been carried out for data from the 1994 National Aboriginal and Torres Strait Islander Survey,26 the 2002 National Aboriginal and Torres Strait Islander Social Survey27 and the 2004–05 National Aboriginal and Torres Strait Islander Health Survey.28 Data from each of these surveys showed that smoking was more prevalent among Aboriginal peoples and Torres Strait Islanders who had less education, were unemployed, were renting rather than owning or buying their own home, and who were in the lower income brackets.26–28 Table 8.3.3 presents these findings for the 2004–05 National Aboriginal and Torres Strait Islander Health Survey, with data for the non-Indigenous population from the National Health Survey of the same year included for comparison.28 When comparing Indigenous and non-Indigenous people of similar socio-economic status, Indigenous people have a higher smoking prevalence than for non-Indigenous people for the same socio-economic indicator.

Experiencing more than one life stressori and feeling financial stress in the previous year (defined as lacking the ability for themselves or another household member to access $2000 in an emergency) were also indicators for increased risk of smoking in Indigenous adults in the 2002 and the 2004–05 national Aboriginal and Torres Strait Islander surveys.27,28 The 2004 survey also reported significant associations between smoking and higher levels of psychological distressii or having a disability or other long term health condition.28 Data from the 2002 National Aboriginal and Torres Strait Islander Social Survey show that Aboriginal and Torres Strait Islanders who had been arrested or incarcerated in the last five years were significantly more likely to be smokers; those who reported all four of ‘arrested in last 5 years’, ‘incarcerated in last 5 years’, ‘used legal services in past 12 months’ and ‘victim of

i For the purposes of this survey, the Australian Bureau of Statistics defined stressors as one or more events or circumstances which a person considered to have been a problem for themselves or someone close to them in the last 12 months, including: serious illness, accident or disability, death of a family member or close friend, divorce or separation, inability to obtain work, alcohol or drug-related problems, being the victim of abuse, overcrowding, discrimination or racism. For a full list refer to the Glossary section of the National Aboriginal and Torres Strait Islander Health Survey 2004–05.29. Australian Bureau of Statistics. 4715.0.55.004. National Aboriginal and Torres Strait Islander Health Survey 2004–05: users’ guide. Canberra: ABS, 2006. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4715.0.55.0042004-05?OpenDocument

ii Assessed by a modified version of the Kessler Psychological Distress Scale to measure non-specific psychological distress. See National Aboriginal and Torres Strait Islander Health Survey 2004–05 for further information.29. Ibid.




violence in past 12 months’ were nearly 10 times more likely to be smokers than those who were not affected by any of these law and justice indicators.27

Although Aboriginal and Torres Strait Islander communities have had different experiences of colonisation, the colonising process has overall had an important influence on ongoing patterns of tobacco use by Aboriginal peoples and Torres Strait Islanders (see Section 8.2). Detailed analyses of the 1994 National Aboriginal and Torres Strait Islander Survey and the 2002 National Aboriginal and Torres Strait Islander Social Survey identify removal from family as significantly related to being a smoker.26,27 After adjusting for age, gender and socio-economic variables, the 2002 Social Survey data showed that Aboriginal and Torres Strait Islander people were twice as likely to be smokers if they had been removed from their natural family.27 The 1994 survey found other factors associated with the colonising process to also be significantly related to smoking behaviour; those who considered the role of elders important, those recognising homeland, and those who spoke English as their main language (for females) were more likely to smoke.26 However, similar indicators in the 2002 survey were not found to be significant (identifying with a clan, tribal or language group, living in homelands/traditional country, having attended a cultural event in the last 12 months).27

Studies that have looked at the association between racism and smoking have found a significant association between the two.31 A study of pregnant Indigenous women in Perth reported that stress related to racial discrimination was a factor contributing to their smoking.32

8.3.3

Prevalence of smoking among pregnant womenData from the 2008 National Perinatal Data Collectioni reports that 50.9% of Indigenous mothers smoked during pregnancy compared to 14.4% of non-Indigenous mothers.33 This prevalence rate for Indigenous women remained relatively stable, at around 50%, between 2001 and 2008.33 Several smaller studies have confirmed that Indigenous women have a higher prevalence of smoking during pregnancy and after giving birth than non-Indigenous women, with reported smoking prevalence ranging from 41‒67%.34–41 An analysis of the 2007 National Perinatal Data Collection shows that smoking rates for Indigenous mothers was highest for those in outer regional areas (56%) and lowest for those in major cities (49.3%).33 Indigenous mothers aged under 20 years reported smoking rates during pregnancy of 53.6%. Smoking rates declined with age, so that 49.6% of mothers aged 35–39 smoked during pregnancy.33 This trend of higher smoking rates during pregnancy among teenage Indigenous women has

i Data for this measure were only available from New South Wales, Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory.33

Table 8.3.3 Prevalence of current daily smoking among Aboriginal peoples and Torres Strait Islanders and the non-Indigenous population aged 18 and over by a range of socio-economic indicators, 2004–05

Current daily smokers s(% rounded)

Age-standardised

rate ratio*

Indigenous people

Non-Indigenous

peoplePersons aged 18 years and over 50 21 2.2Highest year of school completed†Year 12 34 16 1.9Year 11 or below 55 25 1.7Labour force statusEmployed 45 22 1.9Unemployed 66 40 1.9Housing tenureHome owner/purchaser 36 16 2.1Renter 55 34 1.6Household income‡Third income quintile and above 40 20 1.9First and second quintile 55 23 1.9

* Indigenous to non-Indigenous rate ratios are calculated by dividing the proportion of Indigenous people with a particular characteristic by the proportion of non-Indigenous people with the same characteristic.

† Excludes those still attending school.

‡ Gross weekly equivalised cash household income, a standardised measure used by the Australian Bureau of Statistics. In brief, the lower the quintile, the lower the income level. For further information, refer to the National Aboriginal and Torres Strait Islander Health Survey 2004–05 and National Health Surveys 2004–05 Users’ Guides.29,30

Source: ABS 200728 using data from using data from the National Aboriginal and Torres Strait Islander Health Survey 2004–05 and the National Health Survey 2004–05



also been found in other studies in Queensland, South Australia and Western Australia.36,42,43 The South Australian study also reported that the likelihood of smoking heavily (consuming 20 or more cigarettes daily) increased with age, and at all ages except for during their teens, Indigenous women smoked more heavily during pregnancy than non-Indigenous women.42

See Section 8.7.3.5 for health impact of smoking during pregnancy and Section 8.10.13.3 for tobacco action initiatives that address smoking during pregnancy.

8.3.4

Prevalence of smoking among health workersA range of small surveys44–49 and anecdotal evidence50 suggest that Aboriginal and Torres Strait Islander health workers have a substantially higher prevalence of smoking than the general Australian population. Findings have ranged between 38% and 49%,44,46–48 and about 60–64%.45,49 One survey, undertaken as part of the National Aboriginal and Torres Strait Islander Tobacco Control Project, found that 39% of health workers who participated in focus groups for the project were smokers. Lindorff observed that this was likely to be an underestimate of actual smoking rates among health workers, since smokers were noticeably less likely to volunteer to participate.44 Research has found that many Indigenous health workers who smoke, smoke heavily,47 and that tobacco use provides a means of coping with the stressful nature of their workloads.47,49 These studies indicate a need for appropriate support and education for health workers as well as the communities in which they work. See Section 8.10.5 for further information on the role of Indigenous health workers in tobacco control, and Section 8.13.5 on policy and funding initiatives to support the health workforce in Aboriginal and Torres Strait Islander health.

8.3.5

Prevalence of smoking among prisonersSmoking rates among prisoners is generally high, much higher than in the general community.51 The situation is similar, if not worse, for Aboriginal and Torres Strait Islander prisoners. The 2009 Australian Institute of Health and Welfare document, The Health of Australia’s Prisoners, reports that 82% of Indigenous and 80% of non-Indigenous prison entrants in all jurisdictions except the Northern Territory and Tasmania were smokers (‘daily’, ‘weekly’ or ‘irregular’).51 However, rates are different between jurisdictions, as the 2009 New South Wales Inmate Health Survey reported significant differences between Aboriginal and non-Aboriginal prisoner smoking rates. This survey found that 83% of Aboriginal male inmates were current smokers, compared to 71% of non-Aboriginal inmates; among female inmates the rates were 88% and 76% for Aboriginal and non-Aboriginal respectively.52 Importantly, 90% of Aboriginal male inmates and 80% of Aboriginal female inmates said that they would like to quit smoking. In addition, the survey found that Aboriginal inmates smoked significantly fewer cigarettes per day than non-Aboriginal inmates.52 Smoking cessation programs for Indigenous prisoners are discussed in Section 8.10.13.4.

8.3.6

International comparisons with other Indigenous peoplesInternational research has shown that Indigenous groups in settler colonial countries use tobacco at significantly higher levels than the dominant population (Table 8.3.4). Notwithstanding the differences between these populations and their specific cultural and historical circumstances, it is likely that these higher prevalence figures also reflect socio-economic disadvantage, and the legacy of colonisation including experiences of marginalisation, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent adoption and adaption of Western habits and practices.53



Table 8.3.4 Prevalence rates of current smokers for Indigenous and non-Indigenous people in Canada, New Zealand, the United States and Australia

CountryIndigenous people Non-Indigenous people

Indigenous group (year of data)

Prevalence (%)

Ethnic group (year of data)

Prevalence (%)

CanadaFirst Nations on-reserve* (2002/03) 54 58.8

Non-Indigenous† (2009)55 18.0Indigenous off-reserve† (2000/01) 56 51.4Inuit‡ (2004)57 71.0

New Zealand58§ Māori (2008) 45.4European/Other (2008) 21.3Pacific Islanders (2008) 31.4Asian (2008) 12.4

United States59ll American Indian/Alaskan Natives (2004–08) 32.7

Non-Hispanic Blacks (2004–08) 20.6Hispanics (2004–08) 14.4Asian Americans (2004–08) 10.4Non-Hispanic whites (2004–08) 22.5

Australia Aboriginal and Torres Strait Islanders† (2008)1 47.0 Non-Indigenous† (2007–08)60 20.0

* Aged 18 and over

† Aged 15 and over

‡ Aged 18–45

§ Aged 15–64, non-age-standardised rates

ll Aged 18 and over, age-standardised rates



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58. New Zealand Ministry of Health. Tobacco trends 2008. A brief update of tobacco use in New Zealand. Wellington: Ministry of Health, 2009. Available from: http://www.moh.govt.nz/moh.nsf/indexmh/tobacco-trends-2008

59. Barnes PM, Adams PF and Powell-Griner E. Health characteristics of the American Indian or Alaska Native adult population: United States, 2004–2008. National Health Statistics Reports 2010;20 Available from: http://www.cdc.gov/nchs/data/nhsr/nhsr020.pdf

60. Australian Bureau of Statistics. National Health Survey: summary of results, 2007–2008. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4364.0Main+Features12007-2008%20%28Reissue%29?OpenDocument

http://www.ichr.uwa.edu.au/files/user1/AustIndigneousHealthReport.pdf

http://www.fnigc.ca/sites/default/files/ENpdf/RHS_2002/rhs2002-03-technical_report.pdf

http://www.fnigc.ca/sites/default/files/ENpdf/RHS_2002/rhs2002-03-technical_report.pdf

http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2009-eng.php

http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/ctums-esutc_2009-eng.php

http://www.moh.govt.nz/moh.nsf/indexmh/tobacco

http://www.moh.govt.nz/moh.nsf/indexmh/tobacco

http://www.cdc.gov/nchs/data/nhsr/nhsr020.pdf



Section: 8.4.1.1Date of last update: 26 March 2012

8.4

Smoking among Aboriginal and Torres Strait Islander children and teenagers8.4.1

Prevalence

8.4.1.1

National surveysData collected in the National Health Surveys, the 2004 National Aboriginal and Torres Strait Islander Health Survey, and the National Drug Strategy Household Surveys of 1998, 2001, 2004 and 2007 have variously collected data among Aboriginal peoples and Torres Strait Islanders aged 14 or 15 and older, or 18 and older. The most recent national data from the National Aboriginal and Torres Strait Islander Social Surveys of 2002 and 2008 collected data from people aged 15 and older. However, individual year-of-age breakdowns are not published in any of these surveys, meaning it is not possible to provide national smoking rates by individual teenage year. The most recently available public data on smoking prevalence among young Indigenous people is from the 2008 National Aboriginal and Torres Strait Islander Social Survey for the 15–24 years age group; 1 this survey reports that 39% of Indigenous young people aged 15–24 were current daily smokers, compared to 16% of non-Indigenous young people in the same age group (from the 2007–08 NHS).

Only two surveys provide information on national data on smoking prevalence rates, including breakdowns by year-of-age, among Aboriginal and Torres Strait Islander children and teenagers. Data from the National Aboriginal and Torres Strait Islander Survey 1994,2 as reported by the Australian Bureau of Statistics in its Occasional Paper on Smoking among Indigenous Australians published in 1997,3 includes smoking prevalence in Aboriginal and Torres Strait Islander children aged 13 and over. This survey found that smoking rapidly increased with age for both males and females aged between 13 and 17. At age 13, between 5% and 8% of Indigenous children were smokers, and by the age of 17, smoking prevalence was about 45% for Indigenous males and 35% for females. Overall prevalence for Indigenous children aged between 13 and 17 was about 22% for both males and females, but prevalence rose for both sexes in the next age bracket (18‒24) with 61% of males and 53% of females reporting current smoking.2 A broad comparison may be drawn between these figures and those published from the Australian Secondary Students’ Alcohol and Drug (ASSAD) survey from the previous year (1993),4 although it should be noted that the data sets are not methodologically the same. Compared to Indigenous teenagers in 1994, in 1993 Australian school children overall had a higher prevalence of smoking in the age groups 13‒15, after which prevalence levelled out at about 28% for boys and 31% for girls aged 16 and 17,4 lower prevalence than for their Indigenous counterparts. The National Aboriginal and Torres Strait Islander Survey showed that Indigenous males were more likely to smoke than Indigenous females,3 but in the ASSAD data set for Australian school pupils, 17-year-old females had a higher prevalence of smoking than 17-year-old males.4 i

The other data set that has provided useful information on smoking prevalence rates among Indigenous youth is the ASSAD survey from 1996 onwards when self-identification as being of Aboriginal and/or Torres Strait Islander descent was included.6 Table 8.4.1 shows comparative changes in smoking rates among both Indigenous and non-Indigenous students enrolled at mainstream (i.e. non-Indigenous specific) schools. In both age groups, in all survey years, and at all levels of smoking, Indigenous students reported higher levels of smoking than non-Indigenous students. After adjusting for state, education sector, sex, age, academic ability and amount of pocket

i It may be that higher rates of Indigenous smoking in the older age groups in part reflects the fact that the National Aboriginal and Torres Strait Islander Survey questioned teenagers irrespective of their attendance at school, while the ASSAD excludes those not in the education system. It is generally reported in the literature that children outside the school system tend to exhibit higher smoking rates than those remaining at school.5



money available, these differences were significant for most years and smoking behaviours (only three were not significant—see Table 8.4.1). A decline in smoking prevalence among Indigenous students was noted, with most of that change occurring between 1999 and 2002, and little change between 2002 and 2005. Smoking prevalence among non-Indigenous students also declined, but more evenly across the years.6

In 2008, the ASSAD survey included an ‘extension’ whereby an additional 19 schools from rural areas of Western Australia, Queensland, Victoria, South Australia and the Northern Territory were surveyed specifically to increase the rural sample. The increase in the rural sample also increased the Indigenous sample. From the 400 schools surveyed as part of the 2008 ASSAD and the ASSAD Extension, 1317 students identified as Indigenous. Around 35% of 12–15 year old Indigenous students had ever smoked, with 15% smoking in the month before the survey and 12% smoking in the past week. The survey also measured ‘intention to smoke in the next 12 months’, which is considered indicative of students’ receptivity to taking up smoking and is predictive of future smoking among adolescents and adults. Indigenous students had higher mean scores on intention than non-Indigenous students, suggesting that Indigenous students may be more open to taking up smoking.7 This finding is consistent with those of the earlier ASSAD surveys.6

8.4.1.2

State and regional surveysA range of region-specific surveys have been undertaken, varying in size, scope and methodology,8–14 resulting in a spectrum of findings, some of which are summarised below. Some broad similarities may be observed. As would be expected, all surveys confirm that prevalence of smoking increases with age. Studies from Western Australia,8 the Northern Territory,10 New South Wales11 and Victoria12,13 have found that Indigenous teenagers smoke at a higher rate than their non-Indigenous counterparts. A statewide survey in Western Australia (2001–02) indicates prevalence rates for Indigenous young people that are similar to, or possibly slightly higher than for, non-Indigenous young people.9 However, research from rural North Queensland (published in 2004) shows no difference in smoking rates between Indigenous and non-Indigenous students.14 Half of these studies are based in schools. Given the lower rate of high school retention11,14,15 and higher levels of school absenteeism among Indigenous teenagers,10,15 schools-based surveys as a measure of smoking prevalence may not be fully representative of this age group and may result in an underestimate of smoking prevalence, particularly among students in Year 10 and beyond. The 2001–02 Western Australian Aboriginal Child Health Survey showed that Indigenous children aged 12‒17 who did not attend school had substantially higher smoking rates than those who did attend school. Overall, 25% of boys who attended school had smoked, compared to 48% who were not still in school. Among girls, 31% of school attendees were smokers, compared to 64% who were not still in school.9

Three school-based surveys10,11,13and two community-based (i.e. not school-based) surveys8,12 show smoking prevalence rates that are higher among Indigenous compared to non-Indigenous young people. Findings from the

Table 8.4.1 Percentage of students self-identifying as Indigenous and non-Indigenous who have ever smoked, who are monthly smokers, current smokers, and committed smokers in each survey year between 1996–2005* (data not weighted)

Smoking behaviour12–15 year olds 16–17 year olds

1996 1999 2002 2005 1996 1999 2002 2005Ever smoked * * Non-Indigenous 54% 47% 40% 29% 73% 69% 63% 51% Indigenous 61% 61% 50% 47% 78% 76% 75% 66%Monthly smokers† Non-Indigenous 22% 20% 14% 9% 34% 33% 26% 21% Indigenous 30% 32% 22% 20% 48% 49% 39% 36%Current smokers‡ Non-Indigenous 18% 16% 11% 7% 29% 28% 21% 15% Indigenous 27% 28% 19% 17% 44% 43% 29% 33%Committed smokers§ * Non-Indigenous 11% 10% 7% 4% 21% 19% 15% 9% Indigenous 19% 22% 14% 14% 37% 36% 22% 24%

* Differences between Indigenous and non-Indigenous students are significant except for the cells indicated

† Monthly smoking—smoked in the past four weeks

‡ Current smoking—smoked in previous seven days

§ Committed smoking—smoked on three of previous seven days

Source: White V, Mason T and Briggs V 2009 6



2009 Victorian Adolescent Health and Wellbeing Survey, which surveyed young people in schools in years 7, 9 and 11, showed that the proportion of young Aboriginal people who had ever smoked was statistically significantly higher compared to non-Aboriginal people (36.1% compared to 24.9%).13 Young Aboriginal Victorians were also significantly more likely to have smoked in the past year and in the last 30 days. Aboriginal and non-Aboriginal young people who had smoked in the past 30 days were likely to have smoked a similar number of cigarettes per day, with most (50%) smoking less than one per day, and around 20% smoking 6 or more per day. Aboriginal youth were significantly more likely than non-Aboriginal youth to report having ‘very’ or ‘sort of ’ easy access to cigarettes (63.7% versus 47.2%).13

Two earlier school-based studies also show higher rates among Indigenous young people. A study of smoking behaviour among Indigenous primary and high school-aged children in three remote Top End (north Northern Territory) communities in 199710 found that rates of current smokers (those who had smoked in the last week) were higher in most teenage years among the Indigenous population than for the national secondary school population, as reported in Australian Secondary Students’ Alcohol and Drug (ASSAD) survey of 1996.16 The youngest current smoker was aged six, and 6% of children aged 8 and under were smokers. In the teenage years, experimentation and current smoking increased with age. Among pupils aged 16 or more, experimentation with smoking was universal, and half were current smokers, equivalent to the adult smoking prevalence for Aboriginal peoples and Torres Strait Islanders from around the same period.10 A series of surveys undertaken in schools in New South Wales during 1989, 1992 and 199611 also showed that Aboriginal and Torres Strait Islander students aged between 12 and 17 were more likely to smoke than their non-Indigenous counterparts. The most recent of these surveys (1996) found that overall smoking prevalence among children of Aboriginal or Torres Strait Islander descent was 30%, compared to 20% for non-Indigenous children. Smoking prevalence was highest among Indigenous girls (33%), followed by Indigenous boys (27%), non-Indigenous girls (21%) and non-Indigenous boys (19%). Higher patterns of tobacco use were also evident from the earlier years’ survey data.11

In two studies with community-based, rather than school-based, samples similar trends have been observed.8,12 A Western Australian-based study into smoking behaviour among young Indigenous people aged 8‒17 in the Albany community (published in 1997) found that tobacco was most commonly the drug used first among this population group.8 Importantly, most youth (64%) had never smoked tobacco. Frequent smokers (defined as those who had smoked on the day before the interview, and at other times in the preceding week and in the previous four weeks) increased with age, from 4% of the 8‒12 age group to 44% of the 15‒17 age group. Although not directly comparable because of differences in school retention rates, Indigenous children in Albany (both in and out of school) were more likely to have smoked in the past week than secondary school children aged 12–17 in Western Australia in 1990 (36% compared with 21%).8 Another study (in 1997) of a random sample of 174 Aboriginal young people in Melbourne found that 29% aged 12–15 years and 63% aged 16–25 years reported being current smokers.12 A broad comparison of the 12–15 years age group can be made with the ASSAD (school-based) survey of 1996, where 18% of 12–15 year olds reported being current smokers.16 Thirty-one per cent of the Melbourne Aboriginal young people aged 12–25 years had never smoked, and 66% of those who were smoking indicated that they wanted to give up.12

A population-based survey in Western Australia also suggests that smoking prevalence rates may be higher for Indigenous than for non-Indigenous young people. The Western Australian Aboriginal Child Health Survey, which was conducted in Western Australia between 2000 and 2002, gathered information on a broad range of indicators, including smoking,9 and reported smoking prevalence rates similar to those reported in an earlier (1993) Western Australian Child Health Survey.17 While there is a large time gap between these two data sets, the 1993 survey is the only comparable data set for non-Indigenous young people as similar definitions of smoking characteristics were used, definitions that are different to the other national data set, the ASSAD surveysi. Table 8.3.2 presents data on smoking from both of these surveys (2000–02 and 1993) for comparison. For Indigenous youth, the data show that at all age levels, except age 12, more females smoke than males, although these differences are not statistically significant. By age 17 (not shown in Table 8.4.2), Indigenous males and females were smoking at about the same

i Of the young people in the Western Australian Aboriginal Child Health Survey 2000–02 who indicated that they had ‘smoked cigarettes more than once or twice’, all then went on to indicate that they ‘had smoked daily for at least a month at some point in their lives’. These young people were classified as ‘regular smokers’, but clearly this term cannot be interpreted to necessarily mean ‘current smokers’. This makes it difficult to compare to the ASSAD surveys that define smoking characteristics differently. Similarly, the ASSAD surveys define those who have had even ‘a puff’ as ‘ever smokers’, while in the 2000–02 Aboriginal child health survey those who have never smoked and those who have smoked ‘just once or twice’ are classified together.



rate (56% and 60% respectively).9 When comparing rates, non-Indigenous young people appear to be smoking at lower rates than Indigenous young people at almost all age levels, for both males and females, although these differences are not statistically significant. However, considering the time difference between these two data sets, and assuming that the fall in smoking rates observed in the ASSAD surveys between 1996 and 20056 also applies to non-Indigenous Western Australian young people, it could be inferred that by 2000–02 the non-Indigenous youth smoking rates could have been lower than the Indigenous rates observed in 2000–02.

Not all studies agree with the finding that Indigenous adolescents have a uniformly higher prevalence of smoking than non-Indigenous adolescents. A study into smoking behaviour in Indigenous secondary school students in rural North Queensland (published 2004)14 showed that among teenagers in years 8‒12, 24% of Indigenous students smoked overall, compared to 30% of non-Indigenous students. In the younger year groups (8‒10), 18% of Indigenous males and 26% of Indigenous females were smokers, compared to 28% of both sexes among the non-Indigenous students. Prevalence increased with age for both groups, the highest incidence of smoking among students in years 11 and 12 occurring among Indigenous males (46%), followed by non-Indigenous females (38%), Indigenous females (32%) and non-Indigenous males (30%). Although there were reduced levels of participation by Indigenous students in school in the later years, which may have resulted in an underestimate of smoking prevalence among the older age groups, the authors nonetheless comment that their results ‘challenge the belief that Indigenous youth are significantly different in their smoking patterns and behaviours compared to non-Indigenous secondary school students in rural regions’ (p101).14 They attribute this similarity to the greater importance of geographical location, as opposed to ethnicity, as a determinant of smoking in regional areas where students, even those of different ethnic backgrounds, are more likely to be similar in their attitude, beliefs and behaviours regarding cigarette use.14

8.4.2

Age at uptakeAccording to national data, Aboriginal peoples and Torres Strait Islanders who smoke are more likely to have begun smoking at an earlier age than their non-Indigenous counterparts. A comparison between the National Aboriginal and Torres Strait Islander Health Survey and the National Health Survey, both of 2004–05, shows that about 10% of Indigenous adults who were current and former smokers had commenced regular smoking prior to the age of 13, compared with 5% of non-Indigenous current and former smokers. By the age of 18, 68% of current and former Indigenous smokers were smoking regularly, compared with 54% of non-Indigenous current and former smokers. Indigenous people living in non-remote areas were more likely to be smoking before the age of 13 years than Indigenous people living in remote areas (11% compared to 5%).18

Other research has also pointed to an earlier age of uptake of tobacco use among children of Aboriginal and Torres Strait Islander descent.10,19,20 However as with the various prevalence surveys described above, regional variation is evident, reflecting socio-demographic and cultural factors. Within Aboriginal and Torres Strait Islander communities, there is a general perception among adults that children are taking up smoking at around the age of 10.21 Age of uptake is an issue of concern, since an early commencement of smoking increases duration of exposure, and hence risk of development of a range of tobacco-caused diseases.22 Furthermore, research shows that the earlier a young person starts smoking, the more likely they are to become addicted, to continue smoking as adults, and to smoke heavily.23

Table 8.4.2 Comparison of Western Australian Indigenous (2000–02) and non-Indigenous (1993) ‘adolescents who have smoked more than just once or twice’, aged 12–16, by age and sex

Age 12 13 14 15 16 TotalPrevalence of ‘adolescents who have smoked

more than just once or twice’ (% rounded)

IndigenousMales 12 20 26 41 43 27Females 12 26 39 50 55 36Total 12 23 33 45 49 32

Non-IndigenousMales 19 35 40 38 29Females 19 30 42 31 29Total n/a n/a n/a n/a 29

Source: Zubrick et al 20049 and Zubrick et al 199517



Research into substance use among Indigenous and non-Indigenous primary school students in metropolitan and far north Queensland in 1999 found that during primary school years (ages 8‒12), Indigenous and non-Indigenous children experimented with tobacco at comparable rates, with about one in five students in this age bracket having tried smoking.24 The likelihood of experimentation increased with age, 9% of nine year olds reporting having ever smoked, rising to 41% among 12‒13 year old students. There being no significant difference between tobacco use by Indigenous and non-Indigenous children, the authors of this study conclude that the excess uptake noted in the Indigenous population occurs in the early years of secondary school. Another Queensland-based study seems to bear this out—research on secondary school students in North Queensland finding that a small proportion of both Indigenous and non-Indigenous current smokers reported that they had started smoking at the age of seven (3% and 2% respectively), and that 26% of Indigenous and 19% of non-Indigenous smokers had begun smoking by age 12.14 Earlier patterns of uptake have also been reported in Albany, Western Australia. Among current Indigenous smokers aged between 15‒17, the mean age of reported first use of tobacco was 9.7 years.8 Twenty-four per cent began smoking before the age of eight, and 71% had commenced by age 13.

8.4.3

Influences on smoking behaviourAboriginal and Torres Strait Islander young people are affected by the same determinants of smoking as Indigenous adults (see Section 8.3.2). Data from the 1994 National Aboriginal and Torres Strait Islander Survey3 and the 2002 National Aboriginal and Torres Strait Islander Social Survey25 report findings for young people aged 15–24 and show similar associations as for adults between smoking and socio-economic determinants such as employment, drinking alcohol, and being taken away from family as a child.

Aboriginal and Torres Strait Islander young people report similar influences on uptake of smoking to young people everywhere. Being part of a peer group that smokes, smoking among other family members and parents, 9,10,14,21,24 and having a positive attitude towards smoking are strong indicators of smoking behaviour shared by both Indigenous and non-Indigenous young people.5,24 Smoking among Indigenous young people can also be an expression of rebellion, a way of risk-taking, a means of offsetting boredom or alleviating stress, or a way to cope with depression.12,21,26 Experimentation with other substances, such as alcohol and marijuana, also correlates with adoption of smoking.24

The comparatively high rates of smoking among the adult community mean that many Aboriginal and Torres Strait Islander children live in households where smoking is the norm. A study of smoking behaviour among Indigenous primary and high school-aged children in three remote ‘top end’ (north Northern Territory) communities10 found that almost every child (98%) lived with at least one smoker. Children who did not smoke mentioned having a non-smoking family as a reason for being non-smokers. Although the children surveyed demonstrated a reasonable knowledge about the health effects of smoking, tobacco use appeared to be viewed as a normal and expected part of being an adult. It was common for children to be asked to light cigarettes for adults, about one-quarter of the surveyed group having performed this task in the previous week.10 Similarly, focus groups interviewed for the National Aboriginal and Torres Strait Islander Tobacco Control Project found that smokers who, as children, had been asked to procure and light up cigarettes for their parents, were directly influenced into taking up smoking themselves.21 Similar influences were noted in a Northern Territory study, where most participants reported initially stealing their cigarettes from family members and experimenting with cousins and peers. Some were also offered tobacco from family members, were asked to roll or purchase cigarettes for others in the family, or had parents buy their cigarettes for them.27

In this Northern Territory study, participants also reported that a significant influence on their initiation to smoking was the modelling of adult smoking behaviours, not only their own parents but also extended family.27 This is confirmed in Victorian research that has found that the high incidence of smoking among adults, including parents, grandparents and community elders, serves as modelling behaviour for children in Indigenous communities.28 Additionally, parents who smoked appeared to have the expectation that their children would smoke as well, and felt that they could not prevent their children from taking up smoking because they would be seen to be hypocritical. Children also commonly reported obtaining cigarettes from their parents.28 Similarly, urban Aboriginal young people participating in a qualitative study on attitudes to smoking reported a perception that



young people with friends, siblings and teachers who were smokers were more likely to be smokers themselves, and that the culture of sharing and social acceptance of smoking was important in taking up smoking.29

Other geographic and socio-demographic factors are likely to have a bearing on uptake of smoking among Aboriginal and Torres Strait Islander young people. A series of studies from New South Wales11 found that children of Aboriginal or Torres Strait Islander descent were twice as likely to dwell in rural or remote areas. About half of the children reported living with both of their parents, while 48% lived in single parent, step or blended couple families, or with neither parent, compared with 28% of non-Indigenous children. Indigenous children were more than twice as likely as non-Indigenous children to consider their school performance to be below average (15% compared to 6%), and about twice as likely to play truant (29% compared to 15%). Indigenous children also reported missing more school for health reasons than non-Indigenous children (28% compared to 18%) although both groups reported much the same incidence of ill-health (about 15%).11 Other research has found that smoking is connected with lower levels of school performance, absenteeism and stresses in the home.5 Studies of Indigenous youth in other countries have also found stressful life events, financial insecurity and household structure (e.g. single parent households) to influence smoking.30 Forero et al make the observation that these factors, combined with the potential for increased incidence of mental health concerns that may result, are cause for concern in this population group, and are likely to contribute to their higher levels of involvement with tobacco and other substances. Programs to assist families, reduce school absenteeism and increase school retention are suggested ways forward, in collaboration with the communities involved.11

Importantly, a number of protective factors that are associated with reduced likelihood that Indigenous youth will take up smoking have been identified. The positive role modelling of non-smoking family members has been reported to be influential in helping to prevent initiation to smoking.27 A study of American Indian adolescents in the US identified academic orientation, social support, community mindedness, and strong ethnic identity as being protective against smoking.30 These are similar findings to those of a study of Aboriginal young people in Melbourne that identified a number of protective factors for a whole range of health and wellbeing indicators, including smoking. These factors included appreciation of Koori community values, creative activities, sense of responsibility, sense of belonging and community connection, pride in Koori identity and sporting activities.31 Fitness and the desire to play sport have also been directly reported by young people as among the reasons for not taking up smoking at all.12,26

Influences on the uptake of smoking are discussed in greater detail in Chapter 5—Factors influencing the uptake and prevention of smoking.



References1. Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2010 Canberra: ABS,

2010. Available from: http://www.abs.gov.au/ausstats/[email protected]/mf/4704.0


3. Cunningham J. 4701.0 Occasional paper: cigarette smoking among Indigenous Australians, 1994. Canberra: Australian Bureau of Statistics, 1997, Last modified 8 December 2006 [viewed 3 September 2008]. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/ProductsbyTopic/332212A0DAA519A1CA2568BA001B8A5C?OpenDocument#

4. Hill D, White V and Segan C. Prevalence of cigarette smoking among Australian secondary school students in 1993. Australian Journal of Public Health 1995;19(5):445–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8713191

5. Tyas S and Pederson L. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tobacco Control 1999;7(4):409–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10093176

6. White V, Mason T and Briggs V. How do trends in smoking prevalence among Indigenous and non-Indigenous Australian secondary students between 1996 and 2005 compare? Australia and New Zealand Journal of Public Health 2009;33(2):147–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19413859

7. Smith G and White V. Use of tobacco, alcohol, and over-the-counter and illicit substances among Indigenous students participating in the Australian Secondary Students Alcohol and Drug Survey 2008. Report prepared by Centre for Behavioural Research in Cancer, Cancer Control Research Institute, Cancer Council Victoria. Canberra: Drug Strategy Branch, Australian Government Department of Health and Ageing, 2010. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/indig-stu-surv08

8. Gray D, Morfitt B, Ryan K and Williams S. The use of alcohol and other drugs by young Aboriginal people in Albany, Western Australia. Australian and New Zealand Journal of Public Health 1997;221:71-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9141733

9. Zubrick S, Lawrence D, Silburn S, Blair E, Milroy H, Wilkes T, et al. The Western Australian Aboriginal Child Health Survey: the health of Aboriginal children and young people. Perth, Australia: Telethon Institute for Child Health Research, 2004, [viewed September 2007]. Available from: http://www.ichr.uwa.edu.au/waachs

10. Johnston F, Beecham R, Dalgleish P, Malpraburr T and Gamarania G. The Maningrida ‘Be Smokefree’ project. Health Promotion Journal of Australia 1998;8:12-17. Available from: http://search.informit.com.au/documentSummary;dn=459887031427789;res=IELHEA

11. Forero R, Bauman A, Chen J and Flaherty B. Substance use and socio-demographic factors among Aboriginal and Torres Strait Islander school students in New South Wales. Australian and New Zealand Journal of Public Health 1999;23:295-300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10388175

12. Victorian Aboriginal Health Service. Cigarette Smoking. Study of Young People’s Health and Well-being. Fitzroy, Australia: VAHS, 1999.

13. Department of Education and Early Childhood Development. The state of Victoria’s children 2009: Aboriginal children and young people in Victoria. Melbourne, Australia: Department of Education and Early Childhood Development, 2010. Available from: http://www.education.vic.gov.au/about/directions/children/vcams/vcamsreports.htm

14. Lowe J, Saeck L, Brough M, Carmont S-A, Clavarino A and Stanton W. Smoking behaviour among Indigenous secondary school students in North Queensland. Drug and Alcohol Review 2004;23:101-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14965891

15. Australian Government Productivity Commission. Overcoming Indigenous disadvantage: key indicators 2009. Canberra: Australian Government Productivity Commission, 2009. Available from: http://www.pc.gov.au/gsp/reports/indigenous/keyindicators2009

16. Hill D, White V and Letcher T. Tobacco use among Australian secondary students in 1996. Australian and New Zealand Journal of Public Health 1999;23(3):252–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10388168

17. Zubrick S, Silburn S, Garton A, Burton P, Dalby R, Carlton J, et al. Western Australian Child Health Survey: developing health and well-being in the nineties. Perth, Australia: Australian Bureau of Statistics and the Institute for Child Health Research, 1995. Available from: http://www.ichr.uwa.edu.au/files/user20/ichr%204303_5.pdf

18. Australian Bureau of Statistics. 4722.0.55.004—Tobacco smoking—Aboriginal and Torres Strait Islander people: a snapshot, 2004–05 Canberra: ABS, 2007, Last modified 5 July 2007 [viewed January 2008]. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/productsbyCatalogue/D030A9BD9BF14B08CA25730E0021BCE1?OpenDocument


20. Watson C, Fleming J and Alexander K. A survey of drug use patterns in Northern Territory Aboriginal communities:1986-1987. Darwin, Australia: Northern Territory Department of Health and Community Services, 1988.


22. US Department of Health and Human Services. The health consequences of smoking. A report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2004. Available from: http://www.surgeongeneral.gov/library/smokingconsequences/

23. US Department of Health and Human Services. Preventing Tobacco Use Among Young People. A report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 1994. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/1994/index.htm

24. Dunne M, Yeo M, Keane J and Elkins D. Substance use by Indigenous and non-Indigenous primary school students. Australian and New Zealand Journal of Public Health 2000;24:546-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11109696


26. Alford K. Koori Community Smokescreen: cigarette use and attitudes in the Goulburn Valley. Aboriginal and Islander Health Worker Journal 2004;28(6):30–2. Available from: http://search.informit.com.au/documentSummary;dn=148038363859564;res=E-LIBRARY



27. Johnston V and Thomas D. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science and Medicine 2008;67(11):1708–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18938006

28. Murphy M and Mee V. Chapter 6: The impact of the National Tobacco Campaign on Indigenous communities: a study in Victoria. In Hassard, K, eds, Australia’s National Tobacco Campaign: evaluation report vol.1. Canberra: Department of Health and Aged Care, 1999. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-metadata-tobccamp.htm/$FILE/tobccamp_g.pdf

29. Zuo Y, Minniecon S and Hua M. ‘If you want your life to end bad, go ahead and smoke’: a focus group study of Aboriginal and Torres Strait Islander young people’s attitudes and knowledge towards smoking. Health Promotion Journal of Australia 2004;15(1):82–3. Available from: http://search.informit.com.au/search;rs=1;rec=1;action=showCompleteRec

30. Le Master P, Connell C, Mitchell C and Manson S. Tobacco use among American Indian adolescents: protective and risk factors. Journal of Adolescent Health 2002;30:426–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12039512

31. Victorian Aboriginal Health Service. The Strengths of young Kooris: study of young people’s health and well-being. Fitzroy, Australia: VAHS, 2000.



8.5

Types of tobacco used by and levels of consumption among Aboriginal peoples and Torres Strait IslandersAs among the general Australian population, most tobacco used by Aboriginal peoples and Torres Strait Islanders is in the form of conventional manufactured cigarettes, but roll-your-own tobacco, pipes and chewing tobacco are preferred by some smokers.1 The National Aboriginal and Torres Strait Islander Tobacco Control Project undertaken during 2001 reported that ‘chop-chop’ (unbranded loose ‘black market’ tobacco) is also used in some communities.2

8.5.1

Manufactured and roll-your-own cigarettes (‘rollies’)As already noted, most tobacco used by Aboriginal peoples and Torres Strait Islanders is in the form of manufactured cigarettes. The National Drug Strategy Household Surveys of 20013, 20044 and 20075 found that average consumption levels among Indigenous smokers were higher than among other Australian smokers. The 2007 survey reported that among current smokers aged 14 and over, Indigenous people consumed, on average, 115 cigarettes each week (16.4 cigarettes daily) compared to 97 cigarettes per week (14 per day) for other Australian smokers. Indigenous smokers of both sexes smoked more than their non-Indigenous counterparts: Indigenous men smoked 111 cigarettes per week, or 16 per day, compared to 102 cigarettes per week, or 14.5 cigarettes daily for non-Indigenous men smoked; Indigenous women smoked 117 cigarettes weekly, or 17 cigarettes daily, compared to 91 cigarettes per week, or 13 cigarettes daily, for non-Indigenous women.5 For participants in the 2007 survey, male Indigenous smokers smoked slightly less heavily than female Indigenous smokers, but the opposite was true for previous surveys in 2001 and 2004.3,4 The National Drug Strategy Household Survey data should be interpreted with some caution as sample sizes of Indigenous people are low, and survey methods may not capture a representative sample (see note i in Section 8.3). Data from the 2008 National Aboriginal and Torres Strait Islander Social Survey (which has a larger sample size) provides an estimate of the level of cigarette consumption for all Indigenous Australians aged 15 and over of 14.7 cigarettes per smoker per day.6 However, this figure is based on national data, and just as smoking rates vary between locations (see Section 8.3.1), consumption rates are also likely to vary (see below).

The only detailed analysis of national data of Indigenous cigarette consumption levels by age group and gender is from the 1994 National Aboriginal and Torres Strait Islander Survey.7 These data show that Indigenous males tend to have a higher daily consumption than females, and that most smokers of both sexes smoke fewer than 20 cigarettes per day. This survey also showed that the numbers of cigarettes smoked per day increased with age. Most smokers aged between 13 and 17 reported smoking 10 or fewer cigarettes daily, and among the 18‒24 age group, 45% of males and 44% of females were smoking at this level. Average consumption levels increased in the 25‒44 age bracket, with about a third of males smoking between 11 and 20 cigarettes each day, and another third smoking between 21 and 30 per day. Highest average consumption was among women aged 45‒54, among whom 35% smoked between 21 and 30 cigarettes. Overall, only about 8% of Indigenous men, and 5% of Indigenous women reported smoking 31 or more cigarettes daily. Table 8.5.17 summarises consumption levels among Aboriginal and Torres Strait Islanders by gender.

The national data sets indicate that most Indigenous smokers smoke fewer than 20 cigarettes per day,3–,8 and this is supported by local level studies.6,9–14 Several studies conducted in communities across the Northern Territory

Table 8.5.1 Number of cigarettes consumed per day by Aboriginal and Torres Strait Islander smokers aged 13 and over, 1994*

Number of cigarettes smoked

Males Females(% rounded)

1–10 33 37

11–20 30 33

21–30 28 24

31 or more 8 5

Not stated <1 1

* Note: Questions about numbers of cigarettes consumed have not been asked in ABS surveys conducted since 1994.

Source: McLennan W 19967



have estimated rates of tobacco consumption using data on the sale of tobacco from stores and/or wholesalers6,14, with three also collecting self-reported rates11,12,13. Using sales data to estimate consumption has been found to be a practical and non-invasive method of estimating tobacco consumption in small remote communities with mostly Aboriginal populations. These studies have found that Aboriginal people in these remote Northern Territory communities smoke between 611 and 15.813 cigarettes per day. One study in three communities in Arnhem Land (in the Northern Territory’s ‘Top End’)12 found self-reported consumption rates of 10–11 cigarettes/smoker/day and store sales based rates of 8.6–12.9 cigarettes/smoker/day. When comparing ‘lighter smokers’ (<10 cigarettes/day) to ‘heavier smokers’ (≥10 cigarettes/day), ‘heavier smokers’ tended to be older, were more likely to be daily smokers, and were almost three times more likely to be men than women.12 A survey using wholesale tobacco data from Northern Territory remote communities calculated tobacco consumption to be 6.8 cigarettes/day/person aged 15 and over (note that this measure is ‘per person’, not ‘per smoker’), and found that tobacco consumption in 14 Aboriginal communities in the ‘Top End’ was more than double that in eight Central Australian communities (8.6 versus 3.5 cigarettes/day/person aged 15 and over).6 In another study using data of sales from community stores in five Central Australian communities, daily smoking consumption was estimated to be between 5.9 cigarettes/day to 8.3 cigarettes per day (based on assumptions of 70% and 50% smoking prevalence respectively).14 Although smoking prevalence rates may be high in these communities, smoking frequency is low, and in many cases is lower than the daily cigarette consumption rate for non-Indigenous smokers of 14 per day.14 However, it should be noted that most of these studies have been undertaken in the Northern Territory, and just as prevalence varies from community to community, it is likely that consumption levels vary too.

Studies have also reported low levels of nicotine dependence among pregnant Indigenous women. A study of pregnant Indigenous women in a community in north Queensland found that over 60% of current tobacco users smoked 10 or fewer cigarettes per day; furthermore, 40% of these women scored 3 or lower on the Fagerström Test for Nicotine Dependence indicating low physical nicotine dependence.9 Similarly, a Northern Territory study of maternal smoking found that 71% reported smoking 10 or fewer cigarettes per day.10

It is also important to realise that the above figures represent average consumption levels. A number of reports observe that since tobacco is often shared, and its purchase is dependent upon availability of funds, consumption may be sporadic and concentrated around pay days. 2,14,15,16 Research involving urban Indigenous female smokers in Perth showed that about half of those respondents who smoked less often than daily, only smoked in conjunction with drinking alcohol. About the same proportion did not purchase cigarettes themselves since the cultural expectation of sharing cigarettes catered for their needs.17

There are no national data on use of roll-your-own tobacco (‘rollies’) in the Aboriginal and Torres Strait Islander population, but it is likely that use among these groups would be at least similar to or possibly higher than levels among the total Australian population, in part due to its price advantage2 and possibly also because of its facility as a product for chewing, or for blending with cannabis (see Section 8.11.2). Watson et al found that more than a third of Indigenous smokers in surveyed Northern Territory communities smoked hand-rolled cigarettes in 1986‒87.18 A 2008 cross-sectional survey in three Northern Territory communities reported that of 305 smokers aged 16 years and over, 57% smoked both factory-made cigarettes and loose ‘roll-your-own’ tobacco, 34% smoked factory-made cigarettes only, 2% smoked only loose tobacco, and 1% only chewed tobacco.12 In comparison, the National Drug Strategy Household Survey of 2007 found that about 17% of Australian smokers used both roll-your-own tobacco and factory-made cigarettes, and only 5% of all smokers used loose tobacco exclusively.5

8.5.2

‘Chop-chop’Chop-chop is unbranded loose tobacco leaf, sold on the black market at about half the price of properly taxed tobacco on a weight for weight basis.19 Most of its popularity results from its price, but it is also favoured by some due to the common misconception that because it is has not undergone the usual manufacturing into cigarettes, it is has no additives and is less harmful to health.20,21

The National Aboriginal and Torres Strait Islander Tobacco Control Project report found that Aboriginal and Torres Strait Islander communities in Queensland, New South Wales, the Australian Capital Territory, Victoria and Tasmania use chop-chop.2 Chop-chop is popular among these communities for the same reasons that it is popular



with non-Indigenous Australians, but there are no data on the extent of its usage. As with other tobacco products, its use tends to be cyclical, peaking around pay days. Because chop-chop is generally sold in bulk quantities, it is often purchased communally. The belief in these communities that chop-chop serves as a safer alternative to cigarette smoking is cause for concern and needs to be appropriately addressed.2

For further information on chop-chop, refer to Chapter 1 (Section 1.11.2), Chapter 3 (Section 3.27.3), Chapter 13 (Section 13.7.9).

8.5.3

Chewing tobaccoThe various series of national statistics on Aboriginal and Torres Strait Islander smoking behaviour have not reported separately on types of tobacco consumed, and all have excluded chewing tobacco. Information on the chewing of pituri and other bush tobaccos and commercially available loose tobacco comes from local level studies, many of which are considerably dated. Studies indicate that in most Aboriginal and Torres Strait Islander communities across the country prevalence of tobacco chewing is low, although it has been noted to still be common in communities in Central Australia (southern NT, northern SA, and eastern WA).

Only one large-scale study, undertaken in the Northern Territory between 1986 and 1987,18 attempted to quantify this form of tobacco use in the Indigenous population, finding that one-quarter of respondents chewed tobacco. Women were more likely to chew tobacco than men (38% compared to 11%), and it was more popular among older age groups of both sexes, with almost half of the population aged over 60 reporting that they chewed tobacco. This study reported that the uptake of chewing occurred at an early age, young girls being taught to chew by their mothers and grandmothers; however, this study is from the mid-1980s, and little is documented about current uptake practices. Three-quarters of chewers used commercial loose flake or plug smoking tobacco, and one-quarter used bush tobacco. All chewers mixed their tobacco with ash, in the traditional manner (see Section 8.2). Only a small proportion of individuals (4%) both smoked and chewed tobacco.18

However, in this Northern Territory study there was also a strong geographic influence on chewing behaviour. In the Top End region, tobacco was chewed by only 5% of women and 1% of males.18 More recent studies in Arnhem Land communities of the Top End have also reported low levels of chewing tobacco use in this region. A 2008 study reported that only 1% reported using chewing tobacco exclusively12, and in a study from 2000, 7% of current smokers (11 of 161) reported that they also chewed tobacco22.

The rates of chewing tobacco are much higher in the central region of Australia. The 1986–87 NT study discussed above found that 61% of women and 20% of men chewed tobacco. Although there have been no recent large-scale studies measuring rates of use of chewing tobacco in Central Australia, one researcher has recently noted that over 30% of Aboriginal women giving birth at the Alice Springs Hospital regularly chew bush tobacco (pituri).23 Another study in remote South Australia has commented that chewing tobacco ‘is mainly practiced by middle aged and older women who are least likely to smoke’ (pS71).14 Clearly, strategies to address tobacco use in the Central Australia region need to include both chewing and smoking, and need to consider that some people (particularly women) are exclusively chewing tobacco.

Studies in other parts of Australia have shown that tobacco chewing occurs at comparatively low levels. A study of smoking behaviour in two Victorian country towns showed that a very small number Indigenous males (0.8%), and no females, chewed tobacco. In these populations, smoking was a majority behaviour (67% of men and 63% of women being current cigarette smokers).24 Another study on tobacco use among urban-dwelling Indigenous women aged 18 and over who attended an Aboriginal medical service in Perth found that 6% of respondents had chewed tobacco at some time, and of these women, just over half continued to chew regularly.17

The National Aboriginal and Torres Strait Islander Tobacco Control Project provides more recent, anecdotal evidence about continuing use of tobacco in the traditional way, particularly from one of the communities involved in the interviews.2 According to the report, native tobaccos are still prepared according to traditional methods and play a valued role in ceremonies. Controls on the use of tobacco are recalled from the old days but no longer practised. Usage is more popular in remote areas, probably reflecting availability as well as historical patterns of



use. Native leaf is sometimes mixed with commercially available loose-leaf tobacco, such as Drum or Log Cabin, or the commercial tobaccos are chewed on their own.2

The health consequences of chewing tobacco in these communities have not been evaluated. In traditional use, the native tobaccos were typically only seasonally available, and only in particular locations, and their health effects are not studied. It is not yet clear what impact the chewing of readily available loose smoking tobacco will have on disease prevalence,18 although several reports and studies identify that the health outcomes from using smokeless tobacco are likely to be similar to using cigarettes.25 Chewing tobacco is associated with cancers of the lip, oral cavity and pharynx, and for Indigenous people in the Northern Territory the incidence of these types of cancers increased by 6.6% annually between 1991 and 2005, while mortality increased by 4.6% annually in the same time period.26 It is not possible, however, on the basis of available data, to calculate the proportions of these deaths attributable to various forms of tobacco use, there being other contributing factors to causation of these cancers, and overall Northern Territory prevalence of chewing being low. A Taiwanese study has found that betel quid chewing during pregnancy is significantly associated with poorer birth outcomes, including low birthweight and reduced birth length;27 it is possible that chewing pituri has similar effects on birth outcomes, although this has not been investigated.i The historical and cultural elements of native tobacco use are, however, important to the communities in which their use has continued, and any future health campaigns dealing with chewing tobacco would need to be sensitively managed.2,18

8.5.4

Pipe and cigar useNational surveys of Indigenous smoking behaviour have not collected separate data on pipe or cigar smoking. However it is likely that, as among the general Australian population, use of tobacco in these forms is minimal. The National Drug Strategy Household Survey of 2007 found that 8.3% of smokers aged 14 and over reported some level of pipe or cigar use, and only 1.6% of smokers reported pipe or cigar use exclusively.5

The historical associations of pipe use among Indigenous people, particularly strong in parts of Northern Australia, may mean that there are still communities with some levels of pipe smoking (see Section 8.2). Other than anecdotal comments,15,16 there does not appear to be any published information on this subject.

i A study is currently underway through the University of Queensland to investigate the effects of chewing pituri on pregnancy outcomes.23



References1. Ivers R. Indigenous tobacco—a literature review. Darwin, Australia: Menzies School of Health Research and the Co-operative Research Centre for Aboriginal and Tropical Health, 2001.

Available from: http://www.lowitja.org.au/files/crcah_docs/Indigenous_Australians_and_Tobacco.pdf





6. Thomas D, Fitz J, Johnston V, Townsend J and Kneebone W. Wholesale data for surveillance of Australian Aboriginal tobacco consumption in the Northern Territory. Tobacco Control 2011;20:291–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21546515






12. Clough AR, Maclaren DJ, Robertson JA, Ivers RG and Conigrave KM. Can we measure daily tobacco consumption in remote Indigenous communities? Comparing self-reported tobacco consumption with community-level estimates in an Arnhem Land study. Drug and Alcohol Review 2010;30:166–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21355927

13. Ivers R, Castro A, Parfitt D, Bailie R, D’Abbs P and Richmond R. Evaluation of a multi-component community tobacco intervention in three remote Australian Aboriginal communities. Australia and New Zealand Journal of Public Health 2006;30(2):132–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16681333

14. Butler R, Chapman S, Thomas DP and Torzillo P. Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities. Australian and New Zealand Journal of Public Health 2010;34(S1):S71–S75. Available from: http://dx.doi.org/10.1111/j.1753-6405.2010.00557.x


16. Briggs VL, Lindorff KJ and Ivers RG. Aboriginal and Torres Strait Islander Australians and tobacco. Tobacco Control 2003;12(suppl. 2):ii5-8. Available from: http://tobaccocontrol.bmj.com/cgi/content/extract/12/suppl_2/ii5

17. Gilchrist D. Smoking prevalence among Aboriginal women. Aboriginal and Islander Health Worker Journal 1998;22(4):4-6. Available from: http://search.informit.com.au/search;rs=1;rec=1;action=showCompleteRec

18. Watson C, Fleming J and Alexander K. A survey of drug use patterns in Northern Territory Aboriginal communities:1986-1987. Darwin, Australia: Northern Territory Department of Health and Community Services, 1988.

19. Sivyer G. Evidence for a large consumption of blackmarket processed-leaf-tobacco throughout the eastern States of Australia [Letter]. Australian & New Zealand Journal of Public Health 2000;24:344-6.

20. Bittoun R. ‘Chop chop’ tobacco smoking [Letter]. Medical Journal of Australia 2002;77:686-7. Available from: http://www.mja.com.au/public/issues/177_11_021202/bittoun_021202.pdf

21. Saunders J. ‘Chop-chop’ tobacco smoking. The Chronicle 2009;14(3):13. Available from: http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/419/2/Chronicle%20August%2009%20WEB.pdf

22. McDonald S, Maguire G and Hoy W. Validation of self-reported cigarette smoking in a remaote Australian Aboriginal community. Australian and New Zealand Journal of Public Health 2003;27(1):57–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14705268

23. The University of Queensland. Effects of chewing wild tobacco during pregnancy: study. UQ News, (Brisbane, Australia) 2011: Available from: http://www.uq.edu.au/news/?article=23592

24. Guest C, O’Dea K, Carlin J and Larkins R. Smoking in Aborigines and persons of European descent in southeastern Australia: prevalence and associations with food habits, body fat distribution and other cardiovascular risk factors. Australian Journal of Public Health 1992;16:397-402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1296789

25. Ratsch A, Steadman KJ and Bogossian F. The pituri story: a review of the historical literature surrounding traditional Australian Aboriginal use of nicotine in Central Australia. Journal of Ethnobiology and Ethnomedicine 2010;6:26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20831827

26. Zhang X, Condon J, Dempsey K and Garling L. Cancer Incidence and Mortality Northern Territory 1991–2005. Darwin, Australia: Department of Health and Families, 2008. Available from: http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/165/1/Cancer%20Incidence%20%26%20Mortality%20Report2008.pdf

27. Yang M-S, Lee C-H, Chang S-J, Chung T-C, Tsai E-M, Ko AM-J, et al. The effect of maternal betel quid exposure during pregnancy on adverse birth outcomes among aborigines in Taiwan. Drug and Alcohol Dependence 2008;95(1–2):134–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18282667









43950_1994.pdf


ndsatsi.pdf






http://dx.doi.org/10.1111/j.1753-6405.2010.00557




http://search.informit.com.au/search

http://www.mja.com.au/public/issues/177_11_021202/bittoun_021202.pdf

http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/419/2/Chronicle

20WEB.pdf


http://www.uq.edu.au/news/?article=23592

http://www.uq.edu.au/news/?article=23592



http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/165/1/Cancer

20Report2008.pdf




8.6

Smoking cessation and Aboriginal peoples and Torres Strait IslandersThe most recent information on smoker status (including information on ex-smokers and never smokers) is collected in the 2008 National Aboriginal and Torres Strait Islander Social Survey.1 These prevalence rates, adjusted for age so that they are comparable to the non-Indigenous population, are reported in Table 8.6.1i. Further analyses of smoking status data by age, sex and Indigenous status are shown in Table 8.6.2; these data come from the 2004 National Aboriginal and Torres Strait Islander Health Survey.2

Tables 8.6.1 and 8.6.2 show that overall, for both sexes in every age group, a lower proportion of Indigenous Australians have never smoked, compared to the rest of the Australian population. Indigenous Australians are also less likely to have quit smoking (be ex-smokers) than the non-Indigenous population, an exception being among women aged over 55.

There is only limited publicly available national data on tobacco-related behaviour change among Aboriginal peoples and Torres Strait Islanders. The 2008 National Aboriginal and Torres Strait Islander Social Survey shows that in the 12 months prior to the survey, 62% of current daily smokers aged 15 and over had tried to quit or reduce their smoking. The most common reasons given for trying to quit or reduce their smoking were general health, cost and encouragement from family and friends.3 More detailed data about behaviour change related to smoking are available from the National Drug Strategy Household Survey Urban Aboriginal and Torres Strait Islander Supplement conducted in 1994. This survey found that Indigenous smokers were more likely to have made an unsuccessful attempt at quitting than the rest of the population, were less likely to have switched to cigarettes with a lower tar/nicotine brand, and were less likely to have cut down on

i The prevalence rate for Indigenous current smokers reported here (45%) is different to that reported in Section 8.3 (47%). Here, the prevalence rate has been age-standardised to allow comparison to the non-Indigenous current smokers’ rate.

Table 8.6.1 Age-standardised smoker status, Indigenous and non-Indigenous persons, 2008

Smoker status (%)Current smoker* Ex-smoker Never smoked

Indigenous persons 45.1 23.7 31.3Non-Indigenous persons 20.1 28.2 51.7

* Current smoker includes daily, weekly and other current smokers

Source: Australian Bureau of Statistics 2009,1 using data from the 2008 National Aboriginal and Torres Strait Islander Social Survey and the 2007–08 National Health Survey

Table 8.6.2 Smoker status among Aboriginal peoples and Torres Strait Islanders and total Australian population, by sex and age, 2004–05

Smoker status (%) and sexCurrent daily

smokerCurrent smoker

—other*Ex-smoker Never smoked

Sex (M/F) M F M F M F M F18–24 years Indigenous 50 51 3† 1† 13 12 34 36 Non-Indigenous 29 23 4 2† 13 14 54 6225–34 Indigenous 56 54 1† 1† 15 18 28 27 Non-Indigenous 29 23 3 3 24 24 43 5035-44 Indigenous 57 54 2† 5† 15 19 25 22 Non-Indigenous 29 23 2 2 28 25 41 5045–54 Indigenous 50 51 2† 1‡ 30 19 19 29 Non-Indigenous 25 20 2 1† 37 29 36 5055+ Indigenous 35 26 1‡ 1† 43 33 21 40 Non-Indigenous 14 9 1† 1 55 29 30 62

* Current smoker—other is defined as a person who was smoking at least once a week, but not daily

† Estimate has a relative standard error of 25% to 50% and should be used with caution

‡ Estimate has a relative standard error of greater than 50% and is considered too unreliable for general use

Source: Trewin D 20062



the amount smoked daily (Table 8.6.3).4 While the sample size for this survey was large (over 5000), the sample was drawn from urban areas (with populations of more than 1000 people); as it is known that patterns of tobacco use are different from community to community, these data cannot be assumed to be representative of the entire Indigenous population.

A 2010 national study investigating Indigenous smoking issues relevant to the design of anti-tobacco social marketing campaigns found that the key motivators for smoking cessation among their participants were: the importance of family and kin, and the impact of smoking on them; supporting self-efficacy in the quitting process; the cost of smoking, particularly as it impacts on the family; and the adverse impacts of smoking on sport and physical activity.5 A number of smaller studies have focused on some of the cessation issues in Aboriginal and Torres Strait Islander populations. Findings from some of these are summarised here, but it should be noted that study sizes are small and not necessarily representative of the diversity within the Indigenous population. What can be drawn from them is the broad similarity among all Australians who smoke: many wish to quit and have made several attempts to do so; concerns for health are commonly held; and social context is a major influence on smoking behaviour.

A consistent theme in many studies of Indigenous smokers, including those discussed below, is the roles of families in motivating smokers to quit. A qualitative study investigating behaviour around initiating, continuing and quitting smoking found that the family was a prime motivator to quit.6 The health and wellbeing of children was particularly important; smokers cited protecting their children from the health consequences of secondhand smoke, acting as positive role models to their children, and reducing the negative social and economic impacts that smoking was having on the family as reasons to quit smoking. Health was the other motivator for quitting cited by the participants, but rather than referring to the consequences for their own health, participants couched this in terms of protecting the health of their family, or maintaining good health to fulfil their family responsibilities. This study also found that families play a central role in initiation to smoking and maintaining the habit (see Section 8.9).6

The National Aboriginal and Torres Strait Islander Tobacco Control Project (2001) found that among smokers interviewed in its focus groups, 60% had made at least one quit attempt, and 11% had attempted to quit three or more times.7 Asked about behaviour modification in the past 12 months, 43% had tried unsuccessfully to quit, 21% had changed to tobacco with lower tar or nicotine content, and 25% were consuming less tobacco daily. Male smokers were more likely to have changed their smoking behaviour than female smokers. Overall, 40% of smokers were thinking about quitting, 15% were actively trying to quit, and 27% had no intention to quit at that stage. Among those who had successfully quit smoking, a main motivator was either suffering an illness or being diagnosed with a serious illness. So, it was an actual health event, not the threat of future illness, that prompted their quitting. Other reasons for quitting included wanting to live long enough to see their grandchildren grow up, a personal wish to quit, seeing others suffer sickness or dying from tobacco-related illnesses, the cost of tobacco, and their children asking them to give up. Quitters were more likely to have quit at a relatively early age (25 or younger). Half of quitters had done so ‘cold turkey’, suggesting that access to or acceptance of quit resources may be an area for future study. Reasons most commonly given for returning to smoking after an attempt at quitting were succumbing to peer or family influences, stress and addiction.7

Research in 1999 forming part of the evaluation for the National Tobacco Campaign (1997–98) examined the response to the campaign of metropolitan and rural dwelling Indigenous people in Victoria. The study found that intention to quit, and actual quit attempts, were lower than among the general population, despite a generally good understanding of the health effects of smoking.8 Quitting was perceived as a very difficult goal, and with smoking

Table 8.6.3 Comparison of tobacco-related behaviour modification in the last 12 months among Aboriginal peoples and Torres Strait Islanders and the general Australian population, National Drug Strategy Household Surveys 1993 and 1994

Behaviour changed

Proportion of Aboriginal and Torres Strait Islander

population (current smokers)—1994 survey

Proportion of general population (current

smokers)—1993 survey

Unsuccessful quit attempt 45% 40%Change to low tar/nicotine brand 22% 38%Reduced amount smoked per day 32% 41%

Source: Commonwealth Department of Human Services and Health NDSHS Urban Aboriginal and Torres Strait Islander Supplement 19944



being strongly embedded among community mores, peer expectation to smoke and the concomitant lack of social support for quitting combined to discourage quitting (see Section 8.9.1).

Western Australian research on the smoking habits of urban Indigenous woman found that 49% of respondents smoked, 21% had quit and 30% had never smoked.9 Of those who had quit smoking, health concerns were cited as the main reason (49%), followed by pregnancy (12%). This study makes the point that one of the key functions of smoking in this sub-population is its role as a facilitator of friendship bonding and social cohesiveness. This strongly reinforces smoking behaviour, and undermines likelihood of quitting, since to give up smoking is to risk social isolation and alienation.

Smoking by Aboriginal and Torres Strait Islander women during pregnancy remains high (see Section 8.3), and several studies have investigated smoking behaviours in this group. The 2008 National Aboriginal and Torres Strait Islander Social Survey reported that 42% of mothers of children aged 0–3 years used tobacco during pregnancy: 24% used less during their pregnancy, 15.4% did not change their usage behaviour, and 2.7% used more during their pregnancy.10 Studies have found that women may report cutting down the number of cigarettes smoked as a strategy to limit risk to their baby.11,12 In a New South Wales study, 24% of women using tobacco at the beginning of their pregnancy quit, while around 51% decreased their tobacco use (13% stayed the same, and 12% increased their use).13 Among those who quit, a significant proportion may take up smoking again after the birth of the baby.12,14 Two studies of pregnant women in Townsville found that they may have been more motivated and able to quit during their pregnancies.15,16 Both studies found that nicotine dependence, as measured using the Fagerström Test for Nicotine Dependence, was low—over 70% of women in both studies scored low to medium (1–5) on the Fagerström test. One of the studies15 also involved investigating the ‘stages of change’ profiles of their participants, and found that 14% had taken action to give up (‘action’ stage), 55% were thinking about giving up (‘contemplation’ stage), and 31% were not thinking about giving up (‘pre-contemplation’ stage). Importantly, 45% of women had both low nicotine dependency (Fagerström test score 0–5) and were thinking about giving up (‘contemplation’). The mean number of previous quit attempts for this sample was 1.4, with 15% having tried to quit more than 10 times.

Apart from the physical addiction, the barriers to quitting reported by pregnant women include: family pressure to continue smoking; using smoking as a way to manage difficult life circumstances and the related stressors (which were seen to increase during pregnancy); and the perceived social benefits of smoking, as an opportunity for ‘yarning’, relaxation and time out.11,12 Two studies have confirmed some of these reported barriers, finding a significant association between Indigenous women smoking during pregnancy and the numbers of smokers in the household,14,17 having a partner who smokes,17 and higher levels of daily stress.17 Tobacco action initiatives for pregnant Indigenous women are discussed in Section 8.10.13.3.

Studies on tobacco use among Aboriginal health workers have found that the majority of Aboriginal health workers wanted to quit, and/or had made at least one quit attempt in the recent past.7,18,19,20 Relieving stress, particularly stress associated with the job, is commonly cited as a reason for Aboriginal health workers to smoke.7,20,21 Other barriers to quitting that have been reported are lack of support, living/working in a smoky environment, partner smokes, addiction, and the withdrawals that result from quitting.20 Smoking among Aboriginal health workers may impact on their capacity to deliver smoking cessation activities (see Section 8.10.5). Specific tobacco action programs targeting Aboriginal health workers are discussed in Section 8.10.13.1.

Smoking cessation behaviour among young Aboriginal and Torres Strait Islanders is discussed in Section 8.4. Attitudes and beliefs about smoking are discussed further in Section 8.9, and initiatives and policies designed to promote and support quitting among Aboriginal peoples and Torres Straits Islanders are discussed in sections 8.10 and 8.13 respectively. Smoking cessation is discussed in greater detail in Chapter 7.



References1. Australian Bureau of Statistics. 4714.0 National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/abs@.

nsf/DetailsPage/4714.02008?OpenDocument




5. Ipsos-Eureka Social Research Institute and Winangali. Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign. Prepared for the Department of Health and Ageing. Sydney: Ipsos-Eureka Social Research Institute and Winangali, 2010. Available from: http://www.health.gov.au/internet/ctg/Publishing.nsf/Content/home-1/$file/Smoking%20Campaigns%20report.pdf

6. Johnston V and Thomas D. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science and Medicine 2008;67(11):1708–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18938006



9. Gilchrist D. Smoking prevalence among Aboriginal women. Aboriginal and Islander Health Worker Journal 1998;22(4):4-6. Available from: http://search.informit.com.au/search;rs=1;rec=1;action=showCompleteRec



12. Passey M, Gale J, Holt B, Leatherday C, Roberts C, Kay D, et al. Stop smoking in its tracks: understanding smoking by rural Aboriginal women, Conference paper.The 10th National Rural Health Conference. Cairns, Australia: National Rural Health Alliance, 2009. Available from: http://10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf

13. Passey M, Gale J, Stirling J and Sanson-Fisher R. Tobacco, cannabis and alcohol: changes in pregnancy among Aboriginal women in NSW, Conference paper. Primary Health Care Research Conference. Darwin 2010: Adelaide: Flinders University Primary Health Care Research & Information Service, 2010. Available from: http://www.phcris.org.au/download.php?id=6874&spi=3


15. Heath D, Panaretto K, Manessis V, Larkins S, Malouf P, Reilly E, et al. Factors to consider in smoking interventions for Indigenous women. Australian Journal of Primary Health 2006;12(2):131–5. Available from: http://www.publish.csiro.au/paper/PY06032.htm




19. West L, Young D and Lloyd J. A Report on Far North Queensland Aboriginal and Torres Strait Islander health workers. Knowledge, attitudes and beliefs about smoking cessation and prevention. Cairns: Queensland Health, 1998.






47150_2004-05.pdf



ndsatsi.pdf

http://www.health.gov.au/internet/ctg/Publishing.nsf/Content/home

http://www.health.gov.au/internet/ctg/Publishing.nsf/Content/home

20report.pdf





tobccamp_g.pdf

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paper.The

http://10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf




http://www.publish.csiro.au/paper/PY06032.htm







8.7

Morbidity and mortality caused by smoking among Aboriginal peoples and Torres Strait IslandersThis section discusses the major tobacco-caused disease groups leading to illness and death among Australia’s Aboriginal peoples and Torres Strait Islanders, and highlights differences, where they occur, from the general Australian population. The health consequences of smoking are discussed in detail in Chapter 3. National figures on morbidity and mortality due to smoking are provided in Chapter 3, Section 3.30.

The majority of national data appearing in this section comes from two main sources: the Australian Institute for Health and Welfare’s National Mortality Database as analysed and reported in the 2008 and 2010 editions of The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples;1,2 and analysis of 2003 morbidity and mortality data in The Burden of Disease and Injury in Aboriginal and Torres Strait Islander Peoples, 2003.3 Additional data on self-reported health status and long-term health conditions come from the 2004–05 National Aboriginal and Torres Strait Islander Health Survey;4and the 2008 National Aboriginal and Torres Strait Islander Social Survey.5 It should be noted that in many cases what is reported as ‘national’ data is actually data from those jurisdictions where Indigenous data quality is considered adequate. This varies among data sets and is specified where necessary.

8.7.1

Causes of mortality and morbidity among Aboriginal peoples and Torres Strait IslandersAboriginal peoples and Torres Strait Islanders experience poorer health outcomes and have a lower life expectancy than the rest of the Australian population—11.5 years less for males, and 9.7 years less for females (2005–2007 data)i.2 For the period 2005–2009 and for all age groups below 65 yearsii, Indigenous people have at least twice the age-specific death rate of the rest of the Australian population. For those aged between 35 and 54, the death rates for Indigenous Australians are five times higher than among the non-Indigenous population in the same age bracket. For the period 2007–2009, the age-specific rates for infant mortality (deaths among children younger than one year of age) were nearly twice as high among Aboriginal peoples and Torres Strait Islanders than in the total population—7.8 per 1000 live births, compared to 4.0 per 1000 live births.2 For the period 2002–2006 in Queensland, Western Australia, South Australia and the Northern Territory combined, Indigenous people (aged 0–74 years) were four times as likely as non-Indigenous people to die from avoidable deaths—that is, deaths from conditions that could either be prevented from occurring at all, or that could be avoided with early diagnosis and effective treatment.6 At all age levels and for both males and females, death rates from avoidable causes were higher for Indigenous than non-Indigenous people. Encouragingly, the gap between Indigenous and non-Indigenous deaths from avoidable causes has decreased between 1998 and 2006 in these jurisdictions.6

In 2001–2005, the leading cause of death among Aboriginal peoples and Torres Strait Islanders in Queensland, Western Australia, South Australia and the Northern Territory combined was circulatory disease, accounting for about 27% of all Indigenous deaths.1 External events, predominantly accidents, intentional self-harm and assaults, were the next most common causes of death in Indigenous men and women. This was followed by: cancers; endocrine, metabolic and nutritional disorders (mainly diabetes); respiratory diseases; and diseases of the digestive system. In the non-Indigenous population, the leading cause of death for the same time period was also circulatory disease (36.8%), followed by cancers, respiratory diseases and external causes. Age-standardised death rates in 2001–2005 for people aged 35–54 years was higher for all disease categories for Indigenous compared to non-Indigenous people.

i Earlier estimates of differences in life expectancy have cited higher figures than these. The differences come about because of significant changes in the methodology for calculating life expectancy for Indigenous people. These 2005–2007 data can, therefore, not be compared to previously published estimates.

ii Data on age-specific death rates, including infant mortality rates, are based on data from New South Wales, Queensland, South Australia, Western Australia and the Northern Territory.



Aboriginal peoples and Torres Strait Islanders also have higher overall hospitalisation rates than the non-Indigenous population, despite likely under-reporting of Indigenous separations in hospital statistics.1 Adjusting for age, Indigenous people are around twice as likely as non-Indigenous people to be admitted to hospital. In 2005‒06, the leading cause of hospitalisation of Indigenous Australians was for care involving renal dialysis, and Indigenous people were 13.5 times more likely to be admitted for this condition. Indigenous people were about three times as likely to be hospitalised for endocrine, nutritional and metabolic diseases (including diabetes), and twice as likely to be hospitalised for circulatory and respiratory diseases.1

A 2007 study analysed mortality and morbidity data from 2003 to assess the ‘burden of disease’ of various conditions for Indigenous people.3 The ‘burden of disease’ incorporates measures of both mortality (years of life lost due to premature death), and morbidity (years lived with disability), and is expressed in terms of disability-adjusted life years (DALYs). Table 8.7.1 shows the leading causes of DALYs for Indigenous males and females and the rate ratios compared to the total Australian population. In 2003, ischaemic heart disease, type 2 diabetes and anxiety and depression were the top three contributors to the burden of disease for Indigenous males, while for Indigenous females, the leading causes of burden were anxiety and depression, type 2 diabetes and ischaemic health disease. For males, differences between Indigenous and non-Indigenous disease burdens were greatest for homicide and violence (6.8 times the rate), ischaemic heart disease (5.1 times) and type 2 diabetes (4.6 times). For females, these differences were greatest for homicide and violence (11.0 times), alcohol dependence and harmful use (7.9 times) and pneumonia (6.8 times).3

8.7.2

Tobacco-related causes of mortality and morbidity among Aboriginal peoples and Torres Strait IslandersAn analysis of data related to death and illness among Indigenous people calculated ‘the burden of disease’ related to specific health conditions and to 11 risk factors for health, including tobacco smoking.3 Of 11 risk factors for health, tobacco smoking accounts for 12.1% of the burden of disease, more than any of the other risk factors, and

Table 8.7.1 Rate ratios of top 12 leading causes of DALYs by sex, comparing Indigenous Australian and total Australian populations, 2003

Rank

Males Females

Condition% of total

DALYsRate ratio* Condition

% of total DALYs

Rate ratio*

1 Ischaemic heart disease 11.8 5.1 Anxiety & depression 10.0 1.42 Type 2 diabetes 7.0 4.6 Type 2 diabetes 9.5 6.33 Anxiety & depression 5.7 1.7 Ischaemic heart disease 8.9 6.64 Suicide 5.3 3.3 Asthma 4.2 1.75 Road traffic accidents 3.9 2.5 Chronic obstructive pulmonary disease (COPD) 3.7 4.96 COPD 3.9 4.3 Stroke 3.1 3.17 Alcohol dependence & harmful use 3.6 3.7 Road traffic accidents 2.3 3.78 Asthma 2.8 1.2 Alcohol dependence & harmful use 2.2 7.99 Stroke 2.6 2.7 Lung cancer 2.1 3.310 Homicide & violence 2.2 6.8 Homicide & violence 1.9 11.011 Low birthweight 2.0 2.5 Low birthweight 1.8 2.312 Lung cancer 2.0 2.4 Pneumonia 1.7 6.8

All causes 100.0 2.4 All causes 100.0 2.5

* The rate ratio compares the rates of DALYs per 1000 people for the Indigenous Australian population to the total Australian population. For the purposes of this comparison, the total Australian population has been age standardised to the total Indigenous Australian population, 2003.

Source: Various databases as reported in Vos T, Barker B, Stanley L and Lopez A 20073



more than for alcohol and illicit drugs combined. The contribution of tobacco to the total burden of disease was six times greater for Indigenous than non-Indigenous people. An analysis of 2003 data found that of the death and disability (measured by DALYs) attributable to tobacco, three-quarters was accounted for by ischaemic heart disease (37%), chronic obstructive pulmonary disease (COPD—21%) and lung cancer (15%). Stroke accounted for 9% and low birthweight for 5% of DALYs attributable to tobacco. Most (three-quarters) of the burden attributed to tobacco smoking was from mortality. Tobacco contributed to 33% of death and disability from cardiovascular disease, and to 35% of the burden of disease associated with cancer. A greater proportion of the DALYs from cancer was attributable to tobacco in the Indigenous population than in the non-Indigenous population (35% vs. 21%).3 Overall, this study found that tobacco smoking accounts for 20% of deaths among Indigenous Australians,3 and for 17% of the health gap (measured in terms of adjusted DALY rates) between Indigenous and non-Indigenous populations.7

It has been estimated that if all tobacco-caused deaths among Indigenous Australians could be eliminated, then average life expectancy would increase by 2.5 years for males and 1.7 years for females.8 While this may not seem very much, it is important to note that this estimate is averaged across the entire Indigenous population, smoker and non-smoker. If applied only to smokers it would be considerably greater.

The only other studies to quantify deaths due to smoking among Indigenous people were conducted in the Northern Territory (1986‒1995)9 and Western Australia (1983‒1991).10 Although there are methodological weaknesses and the findings should not be generalised to the total Indigenous population, the studies provide at least some indication of the health impact of tobacco among Australia’s Indigenous peoples. The two reports are in broad accordance with each other and with the national data reported above.

The Northern Territory study (1986–1995) found that smoking caused 23% of deaths among Indigenous males, and 17% of deaths among Indigenous females in the Northern Territory.9 In the non-Indigenous Northern Territory population, 22% of male deaths and 11% of female deaths were attributable to smoking. Although there was no regional variation among deaths due to smoking in the non-Indigenous population, regional differences in Indigenous smoking patterns (see also Section 8.3.1), meant that Indigenous people in the ‘Top End’ of the Northern Territory were more likely to die from disease caused by smoking compared to those living in the centre. Most deaths due to smoking were caused by COPD, ischaemic heart disease, lung cancer, stroke, pneumonia and oropharyngeal cancer.9 Adjusting death rates to take into account differences in age distribution within the Indigenous compared with the non-Indigenous populations, the Northern Territory report found that Indigenous women had an age-adjusted smoking attributable death rate of 251 per 100 000, more than six times higher than that of non-Indigenous women (38 deaths per 100 000). The rate for Indigenous males was more than three times higher than that of their non-Indigenous counterparts (457 per 100 000 compared to 145 per 100 000).9

The Western Australian study (1983–1991) estimated that tobacco use caused 13% of all deaths among Aboriginal people, compared to 16% of all deaths in the Western Australian population. Ischaemic heart disease was the major killer, followed by lung cancer and chronic bronchitis.10 Indigenous females died at almost four times the rate of non-Indigenous females (118 deaths per 100 000 compared to 32 per 100 000) and Indigenous males died from tobacco-caused illness at nearly two-and-a-half times the rate of non-Indigenous males (271 deaths per 100 000 compared to 113 per 100 000).10

Both reports note that death rates for tobacco-caused diseases increased substantially at an earlier age among Indigenous people than for non-Indigenous people. The Northern Territory study noted that increases in tobacco-caused morbidity occurred from 35 years of age compared to 45 years of age;9 the Western Australian report found that nearly half of all tobacco-caused deaths occurred before the age of 55 in Indigenous population, compared to only about 11% of deaths in the non-Indigenous population.10

Data from the Australian Institute of Health and Welfare’s National Hospital Morbidity Database shows that Indigenous people are substantially more likely to be hospitalised due to illness caused by tobacco.i In 2006–07 to 2007–08, Indigenous Australians had four times the rate of hospitalisations with a principal diagnosis related to tobacco use as non-Indigenous Australians.5 Although Indigenous males had a slightly higher rate of tobacco-related hospital encounters than Indigenous females, the difference between Indigenous and non-Indigenous

i For the period reported here, this database includes information from New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory. Data from Tasmania and the Australian Capital Territory were not deemed acceptable for analytical purposes.5



hospitalisations was greater for females than males. While Indigenous males were admitted to hospital at 3.2 times the rate for non-Indigenous males, Indigenous women had 5.1 times the admission rate of non-Indigenous women.5 Similarly high rates have been found in earlier studies in the Northern Territory (1993–1995)9 and Western Australia (1983–1991).11

Another measure of morbidity is through self-reported health status. The 2002 and 2008 National Aboriginal and Torres Strait Islander Social Surveys and the 2004–05 National Aboriginal and Torres Strait Islander Health Survey provide useful data to compare the self-reported health status and health conditions of smokers versus non-smokers.4,5 In each of these surveys, Indigenous Australians who smoked reported poorer health status than those who did not smoke. In 2008, of those who had never smoked, 53% reported excellent/very good health and 16% reported fair/poor health; in contrast, among current smokers, 39% reported excellent/very good health while 25% reported fair/poor health.5 In comparison to Aboriginal peoples and Torres Strait Islanders who had never smoked, those who were daily smokers were more likely to report:

< high/very high levels of psychological distress: 32% compared with 20% (2004–05 National Aboriginal and Torres Strait Islander Health Survey)

< having a disability or long-term health condition: 40% compared with 31% (2002 National Aboriginal and Torres Strait Islander Social Survey)

< having a profound or severe core activity restriction such as self-care, mobility or communication: 9% compared with 6% (2002 National Aboriginal and Torres Strait Islander Social Survey).4

However, among Indigenous people aged 35 years and over, similar proportions of current daily smokers (89%), ex-smokers (94%) and never smokers (90%) reported having at least one long-term health condition (2004–05 National Aboriginal and Torres Strait Islander Health Survey ).4

8.7.3

Diseases and conditions related to smokingAs described above, tobacco is a causal, contributing or complicating factor in many of the disease processes contributing most to death and disability among Indigenous people. This sub-section considers the specific diseases and conditions related to smoking: circulatory diseases, cancers, respiratory diseases, diabetes, and pregnancy-related conditions.

8.7.3.1

Circulatory diseasesThe leading cause of death among Aboriginal peoples and Torres Strait Islanders is circulatory disease, accounting for almost 27% of all deaths (2001–05).1 Circulatory diseases include ischaemic heart disease, stroke and other diseases of the circulatory system for which smoking is a major risk factor, and rheumatic heart disease, which is not associated with smoking. Indigenous men and women experience higher mortality rates from circulatory diseases at every age compared with the non-Indigenous population. The burden of excess mortality is greatest among Indigenous men aged between 25 and 44 (the death rate for Indigenous men being 9‒11 times that of non-Indigenous men), and for Indigenous women aged 35‒54 (around 12 times the death rate for non-Indigenous women). Overall, about three times as many Indigenous people die from circulatory diseases as would be expected, based on the rates for the non-Indigenous population.1 Indigenous people in Queensland, Western Australia, South Australia and the Northern Territory (2002–06) were 4.6 times as likely to die from ischaemic heart disease than non-Indigenous people.12

The high prevalence of smoking, diabetes, obesity and sedentary lifestyle in the Aboriginal and Torres Strait Islander populations contributes to the incidence of cardiovascular diseases in their communities. National1 and regional13–16 studies have shown a high incidence of multiple risk factors for heart disease among the Indigenous population, especially smokers.4 In 2004–05, 30% of current smokers and 37% of former smokers reported having heart or circulatory disease.4



8.7.3.2

CancersState and national cancer data sets consistently show that the incidence rates among Indigenous Australians for all cancers combined are similar or lower than for other Australians. However, certain types of cancers (e.g. lung cancer and mouth/lip cancers) have higher incidence rates, and for many cancers higher mortality rates have been reported for Indigenous people.1,17–21 Data from the Australian Institute of Health and Welfare National Cancer Statistics Clearinghouse for 2000–04i indicate that the most common cancers among Indigenous males were lung, bronchus and trachea, prostate and colorectal, while for Indigenous women the most common cancers were breast, lung, bronchus and trachea, and colorectal.1 Between 2001 and 2005, about 15% of Indigenous deaths were caused by cancer, compared to nearly 30% of deaths in the total Australian population.1 However, the rate of death from cancer is higher for Indigenous Australians than for non-Indigenous Australians (1.4 times higher for men, and 1.5 times higher for women). Among Indigenous men, most cancer deaths occurred due to malignancies of the respiratory and intrathoracic organs (30% of total cancer deaths), cancers of the digestive organs (30%) and cancers of the lip, oral cavity and pharynx (9%). The most common causes of cancer death in Indigenous women were malignancies of the respiratory and intrathoracic organs (21% of total cancer deaths), followed by cancers of the digestive organs (21%) and reproductive organs (14%).1

Analysis of combined data from the cancer registries of South Australia, the Northern Territory and Western Australia20 shows that lung cancer is the most commonly diagnosed cancer for Indigenous people (74.8 per 100 000)—1.6 times the rate of non-Indigenous people (47.1 per 100 000). Lip/mouth/pharynx cancer occurs at twice the rate for Indigenous people compared to non-Indigenous people (30.9 per 100 000 compared to 15.2 per 100 000). Alcohol use can also cause these and other diseases, and when combined with smoking, acts synergistically to greatly increase the incidence of cancers of the oral cavity, oesophagus and larynx.22 The comparative death rates from lung cancer and lip/mouth/pharynx cancers are higher for Indigenous people than non-Indigenous people (1.6 times and 4.5 times respectively).20 Similar trends are reported in other analyses of data from the Northern Territory (1991–2005)19 and Queensland (1997–2006).21 Data from the Northern Territory also show that while lung cancer declined in incidence and mortality among non-Indigenous Territorians and Indigenous women between 1991 and 1995 and 2001 and 2003, there was little reduction among Indigenous males (among whom smoking rates are highest).19

Indigenous Australians appear not to suffer worse survival rates for those cancers for which all Australians experience poor survival outcomes (such as lung cancer). However for cancers that respond more positively to treatment, Indigenous Australians have lower survival rates. Indigenous Australians are also more likely to have an advanced stage of disease at the time of diagnosis. These poorer outcomes are suggestive of shortcomings in health services available to these communities, and may also reflect language and cultural barriers.17,23,24

8.7.3.3

Respiratory diseasesRespiratory diseases include chronic bronchitis, emphysema, asthma, influenza and pneumonia. Smoking is a direct cause of chronic bronchitis, emphysema and pneumonia, and smokers have a higher incidence of poor asthma control and respiratory infections.22 As with other disease entities reported in this chapter, the burden of respiratory disease is felt most heavily in younger age groups in the Indigenous population. In 2001–05 among Indigenous males aged 35‒44, age-specific death rates were 22 times higher than in their non-Indigenous counterparts, and for Indigenous women in this age group, death rates were 20 times higher than for corresponding non-Indigenous women.1

In the Indigenous population in 2004–05, 34% of current smokers and 37% of ex-smokers aged 35 and over reported that they had a respiratory disease.4 Other contributing factors to respiratory and lung disease include living in dusty regions, or exposure to smoke from wood fires.25 These environmental factors may also be responsible for influencing disease rates in some Indigenous communities.

i Data on Indigenous cancer rates come from the cancer registries of South Australia, Western Australia, the Northern Territory and Queensland.



8.7.3.4

DiabetesAs well as being life threatening in its own right, diabetes mellitus (also known as type 2 diabetes) can lead to a range of other serious health problems, including coronary heart disease, stroke, peripheral vascular disease, kidney disease, eye disease,26 and complications in pregnancy and childbirth.27 Smokers with diabetes are at increased risk of illness and premature death, mainly through the development of cardiovascular disease in its various forms.28 There is emerging evidence that smoking may also be a contributing factor to an increased risk of developing diabetes, although more research is needed.28–32 Being overweight, having an unbalanced diet and lack of physical activity are major risk factors for developing diabetes,29,33 and each is more common in the Indigenous than the non-Indigenous population,1 and among Indigenous smokers than Indigenous non-smokers.4

The self-reported prevalence of diabetes is three times higher among Indigenous Australians (2004–05 National Aboriginal and Torres Strait Islander Health Survey) than among non-Indigenous Australians (2004–05 National Health Survey), and Indigenous Australians are more likely to experience earlier disease onset, and are more likely to die at an earlier age than diabetic non-Indigenous Australians.1 In 2006–07, Indigenous Australians were almost eight times more likely to be hospitalised for diabetes complications and 18 times more likely to die of diabetes than non-Indigenous Australiansi.12 National data show that in 2004–05, more than 1 in 10 (13%) Indigenous people aged 35 or more who were current smokers reported having diabetes or high sugar levels. Ex-smokers were twice as likely to report having diabetes or high sugar levels compared with current smokers. Ex-smokers with diabetes or high sugar levels were also twice as likely to be overweight or obese compared with smokers with the same conditions, possibly reflecting quitting behaviour following diagnosis.4

8.7.3.5

Smoking in pregnancy, and maternal and child health outcomesAs noted in Sections 8.3 and 8.6, national and state data and local-level studies show that Indigenous women have a higher prevalence of smoking during pregnancy and after giving birth than non-Indigenous women.

Smoking in pregnancy is a major risk factor for preterm delivery, complications in childbirth, foetal growth restriction, stillbirth, low birthweight and infant mortality.22 Infants who are born small for their gestational age are more likely to suffer a range of adverse health outcomes including having an impaired immune system, increased mortality and ill-health in infancy, and subnormal growth patterns.34 Smoking is also a cause of sudden infant death syndrome, whether the baby has been exposed to smoking before birth or in the home following birth.22 Long-term effects of smoke exposure during pregnancy may include poorer academic performance, lower final attained height, and a lower likelihood of employment in managerial or professional fields, even after adjusting for social class and other confounding factors.35 On this basis, it can be said that maternal smoking in pregnancy may be damaging to the health of at least two generations.36

The poorer health outcomes associated with smoking in pregnancy—low birthweight, premature birth, and stillbirth or death in the first four weeks of life (perinatal deaths)—are more prevalent among Aboriginal and Torres Strait Islander women than non-Indigenous women.1,37 In 2008, the perinatal death rate of babies born to Aboriginal or Torres Strait Islander mothers was 1.8 times that of non-Indigenous mothers (17.3 per 1000 births compared to 9.7).37 Babies of Indigenous parents have four times the relative risk of dying from sudden infant death syndrome than other Australian babies.38 Other than smoking, factors that impact upon maternal and child health outcomes include socio-economic circumstances, and mother’s age during pregnancy.39 Indigenous mothers are on average younger than their non-Indigenous counterparts, and are more likely to be disadvantaged.1

A small number of studies have specifically looked at birth outcomes in relation to smoking during pregnancy among Aboriginal and Torres Strait Islander mothers. A South Australian study concluded that about 20% of preterm births, 48% of babies being born small for their gestational age, and 35% of babies with low birthweight could be attributed to smoking in this population group. Among non-Indigenous births, 11% of preterm births, 21% of babies small for gestational age and 23% with low birthweight could be attributed to maternal smoking.36

i Data are from New South Wales, Victoria, Queensland, Western Australia, South Australia and public hospitals in the Northern Territory.



A Queensland study investigating the effect of smoking on preterm births and low birthweight found that both Indigenous and non-Indigenous smokers had poorer birth outcomes than non-smoking Indigenous and non-Indigenous women; there was no significant difference in birth outcomes between Indigenous and non-Indigenous smokers.40 Other studies of Indigenous birth outcomes have found significant associations between smoking and small for gestational age,41 low birthweight42 and ‘poor birth outcomes’ (low birthweight and/or preterm).43 A Western Australian study found that the risk of sudden infant death syndrome for babies born to Indigenous mothers who smoke is nearly three times greater than for babies of non-smoking Indigenous women.44

See also Chapter 1, Section 1.10.1, and Chapter 9, Section 9.5.2.

8.7.4

Exposure to secondhand smoke and its health effectsSecondhand tobacco smoke is also a health concern. Babies and children living in a smoky environment experience higher rates of sudden infant death syndrome, exacerbation of asthma, a greater risk of developing acute lower respiratory tract infections such as bronchitis and pneumonia, and increased risk of middle ear infections. Adults exposed to secondhand smoke are more likely to develop a range of diseases including coronary heart disease, lung cancer and other respiratory problems.45 The health risks from exposure to secondhand smoke are discussed in detail in Chapter 4.

Data from the 2008 National Aboriginal and Torres Strait Islander Social Survey2 show that 68% of Aboriginal and Torres Strait Islander people aged 15 years and over were living in a household with at least one current daily smoker, and 26% were living in a household where someone usually smoked inside.2 People living in remote areas were more likely to be living with a current daily smoker than in non-remote areas, although the proportions of people living with someone who smoked inside the home were similar for remote and non-remote residents. Almost two-thirds (63%) of Indigenous children aged 0–14 years lived with one or more regular smokers, and 21% of Indigenous children were regularly exposed to secondhand smoke in the home. Non-Indigenous children in the same age group were far less likely either to live with a smoker (32%), or to be exposed to secondhand smoking indoors (7%).4

Aboriginal and Torres Strait Islander women are more likely than non-Indigenous women to be exposed to secondhand smoke during pregnancy, and this may impact on birth outcomes. A study of pregnant Aboriginal women in Western Australia reported an association between exposure to secondhand smoke and an increased risk of having low birthweight and/or preterm babies.43 In a study of maternal smoking in the Northern Territory, 31% of the households of the pregnant participants included people who smoked inside during the pregnancy. Importantly, the birth of the child was associated with many of these households becoming smokefree indoors, with 12% reporting smoking indoors at one month after the birth, and 16% at seven months.46

Smaller regional studies have also reported that babies born to Indigenous families are significantly more likely to be exposed to secondhand tobacco smoke in the home than non-Indigenous babies. Research from Western Australia found that 80% of Indigenous babies in a sample studied in Perth were regularly exposed to tobacco smoke.47 A study from Queensland found that 40% of Indigenous infants were exposed to smoke in the home, compared to 20% of non-Indigenous babies.48 Research from three remote top end (north Northern Territory) communities reported that 98% of Indigenous primary or high school-aged children lived with at least one smoker, and 43% lived with five or more smokers.49 Indigenous children have more than three times the incidence of ear and hearing problems of non-Indigenous children,1 for which secondhand smoke is likely to be at least partially responsible. A Western Australian study found that exposure to secondhand smoke was a significant predictor of otitis media in Aboriginal children.50

The comparatively high smoking rates among Indigenous adults mean that many Aboriginal and Torres Strait Islander children live in households where smoking is the norm, which is not only likely to affect their health, but also their own attitudes to smoking (see Section 8.4.3).



References1. Australian Bureau of Statistics and Australian Institute of Health and Welfare. 4704.0 The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2008. cat. no. AIHW

21. Canberra: ABS, 2008. Available from: http://abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4704.02008?OpenDocument


3. Vos T, Barker B, Stanley L and Lopez A. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland, 2007. Available from: http://www.uq.edu.au/bodce/index.html?page=68411



6. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health performance framework: detailed analyses. cat. no. IHW 22. Canberra: AIHW, 2009. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468199&tab=2

7. Vos T, Barker B, Begg S, Stanley L and Lopez AD. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. International Journal of Epidemiology 2009;38(2):470–7. Available from: http://ije.oxfordjournals.org.ezp.lib.unimelb.edu.au/content/38/2/470.short

8. Arnold-Reed D, Holman CD, Codde J and Unwin E. Effects of smoking and unsafe alcohol consumption on Aboriginal life expectancy. Medical Journal of Australia 1998;168(2):95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9469197

9. Measey M, d’Espaignet E and Cunningham J. Adult morbidity and mortality due to tobacco smoking in the Northern Territory 1986-1995 Darwin, Australia: Northern Territory Government Department of Health and Community Services, 1998. Available from: http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/109/1/mortality_morbidity_smoking_1986.pdf

10. Unwin C, Thomson N and Gracey M. The impact of tobacco smoking and alcohol consumption on Aboriginal mortality and hospitalisation in Western Australia: 1983–1991. Perth: Health Department of Western Australia, 1994.

11. Unwin C, Gracey M and Thomson N. The impact of tobacco smoking and alcohol consumption on aboriginal mortality in Western Australia, 1989-1991. Medical Journal of Australia 1995;162(9):475–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7746204

12. Australian Government Productivity Commission. Overcoming Indigenous disadvantage: key indicators 2009. Canberra: AGPC, 2009. Available from: http://www.pc.gov.au/gsp/reports/indigenous/keyindicators2009

13. Leonard D, McDermott R, O’Dea K, Rowley K, Pensio P and Sambo E. Obesity, diabetes and associated cardiovascular risk factors among Torres Strait Islander people. Australian and New Zealand Journal of Public Health 2002;26:144-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12054333

14. Guest C, O’Dea K, Carlin J and Larkins R. Smoking in Aborigines and persons of European descent in southeastern Australia: prevalence and associations with food habits, body fat distribution and other cardiovascular risk factors. Australian Journal of Public Health 1992;16:397-402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1296789


16. Thompson P, Bradshaw P, Veroni M and Wilkes E. Cardiovascular risk among urban Aboriginal people. Medical Journal of Australia 2003;179:143–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12885283

17. Cunningham J, Rumbold A, Zhang X and Condon J. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. The Lancet Oncology 2008;9(6):585–95. Available from: http://www.thelancet.com/journals/lanonc/article/PIIS1470204508701505/abstract

18. Roder D and Currow D. Cancer in Aboriginal and Torres Strait Islander people of Australia. Asian Pacific Journal of Cancer Prevention 2009;10(5):729–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20104959

19. Zhang X, Condon J, Dempsey K and Garling L. Cancer Incidence and Mortality Northern Territory 1991–2005. Darwin, Australia: Department of Health and Families, 2008. Available from: http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/165/1/Cancer%20Incidence%20%26%20Mortality%20Report2008.pdf

20. Threlfall T and Thompson J. Cancer incidence and mortality in Western Australia, 2007. Statistical series no. 86. Perth: Department of Health, Western Australia, 2009. Available from: http://www.health.wa.gov.au/docreg/Reports/Diseases/Cancer/WACR_Cancer_incidence_mortality_main_2007.pdf

21. Moore S, O’Rourke P, Mallitt K, Garvey G, Green A, Coory M, et al. Cancer incidence and mortality in Indigenous Australians in Queensland, 1997–2006. Medical Journal of Australia 2010;193(10):590–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21077815


23. Miller J, Knott V, Wilson C, Cunningham J, Condon J and Roder D. Aboriginal and Torres Strait Islander Cancer Control Research Project. Canberra: Australian Government, 2010. Available from: http://www.canceraustralia.gov.au/publications/aboriginal-and-torres-strait-islander-cancer-control-research-report

24. Lowenthal R, Grogan P and Kerrins E. Reducing the impact of cancer in Indigenous communities: ways forward [Conference report]. Medical Journal of Australia 2005;182:105–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15698352

25. Environment Australia. Australia state of the environment report 2001. Fact sheet: Air quality. Canberra: Department of the Environment and Heritage, Australian Government, 2002. Available from: http://www.environment.gov.au/soe/2001/publications/fact-sheets/air.html

26. Diabetes Australia. Staying well with diabetes. Talking diabetes No.35. 2010. Available from: http://www.australiandiabetescouncil.com/Resources/PDFs/NDSS-Information-Sheets/STAYING-WELL-2010.aspx



http://www.uq.edu.au/bodce/index.html?page=68411





http://ije.oxfordjournals.org.ezp.lib.unimelb.edu.au/content/38/2/470.short


http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/109/1/mortality_morbidity_smoking_1986.pdf

http://digitallibrary.health.nt.gov.au/dspace/bitstream/10137/109/1/mortality_morbidity_smoking_1986.pdf









http://www.thelancet.com/journals/lanonc/article/PIIS1470204508701505/abstract



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20Report2008.pdf

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http://www.surgeongeneral.gov/library/smokingconsequences

http://www.canceraustralia.gov.au/publications/aboriginal


http://www.environment.gov.au/soe/2001/publications/fact-sheets/air.html

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http://www.australiandiabetescouncil.com/Resources/PDFs/NDSS-Information-Sheets/STAYING-WELL-2010.aspx



27. Taylor R and Davison J. Type 1 diabetes and pregnancy. British Medical Journal 2007;334(7596):742–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17413175

28. Haire-Joshu D, Galasgow R and Tibbs T. Smoking and diabetes. Diabetes Care 2003;26(suppl. 1):S89–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12502627

29. Schulze M and Hu F. Primary prevention of diabetes: what can be done and how much can be prevented? Annual Review of Public Health 2005;26:445–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15760297

30. Perry I. Commentary: smoking and diabetes - accumulating evidence of a causal link. International Journal of Epidemiology 2001;30(3):554–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11416082

31. Patja K, Jousilahti P, Hu G, Valle T, Qiao Q and Tuomilehto J. Effects of smoking, obesity and physical activity on the risk of type 2 diabetes in middle-aged Finnish men and women. Journal of Internal Medicine 2005;258(4):356–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16164575

32. Houston T, Person S, Pletcher K, Iribarren C and Kiefe C. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. British Medical Journal 2006;332(7549):1064–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16603565

33. Diabetes Australia. What is diabetes? Talking Diabetes no.42. Canberra: Diabetes Australia, 2010. Available from: http://www.australiandiabetescouncil.com/Resources/PDFs/NDSS-Information-Sheets/WHAT-IS-DIABETES-2010.aspx

34. Ferro-Luzzi A, Ashworth A, Martorell R and Scrimshaw N. Report of the IDECG Working Group on effects of IUGR on infants, children and adolescents: immunocompetence, mortality, morbidity, body size, body composition, and physical performance. European Journal of Clinical Nutrition 1998;52 (suppl. 1):S97–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9511026

35. Strauss RS. Adult functional outcome of those born small for gestational age: twenty-six-year follow-up of the 1970 British Birth Cohort. Journal of the American Medical Association 2000;283(5):625–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10665702

36. Chan A, Keane R and Robinson J. The contribution of maternal smoking to preterm birth, small for gestational age and low birthweight among Aboriginal and non-Aboriginal births in South Australia. Medical Journal of Australia 2001;174(8):389–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11346081

37. Laws P, Li Z and Sullivan E. Australia’s mothers and babies 2008. Perinatal statistics series no.24 cat. no. PER 50. Canberra: Australian Institute of Health and Welfare, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442472399

38. Alessandri L, Chambers H, Blair E and Read W. Perinatal and postneonatal mortality among Indigenous and non-Indigenous infants born in Western Australia, 1980–1998. Medical Journal of Australia 2001;175(4):185–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11587276

39. Lewis LN, Hickey M, Doherty DA and Skinner SR. How do pregnancy outcomes differ in teenage mothers? A Western Australian study. Medical Journal of Australia 2009;190(10):537–41. Available from: http://www.mja.com.au/public/issues/190_10_180509/lew11058_fm.html

40. Wills R and Coory M. Effect of smoking among Indigenous and non-Indigenous mothers on preterm birth and full-term low birthweight. Medical Journal of Australia 2008;189(9):490–4. Available from: http://www.mja.com.au/public/issues/189_09_031108/wil10215_fm.pdf

41. Panaretto K, Lee H, Mitchell M, Larkins S, Manessis V, Buettner P, et al. Risk factors for preterm, low birth weight and small for gestational age birth in urban Aboriginal and Torres Strait Islander women in Townsville. Australian and New Zealand Journal of Public Health 2006;30(2):163–170. Available from: http://doi.wiley.com/10.1111/j.1467-842X.2006.tb00111.x

42. Humphrey M and Holzheimer D. A prospective study of gestation and birthweight in Aboriginal pregnancies in far north Queensland. Australian and New Zealand Journal of Obstetrics and Gynaecology 2000;40(3):326–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11065042

43. Eades S, Read AW, Stanley FJ, Eades FN, McCaullay D and Williamson A. Bibbulung Gnarneep (‘solid kid’): causal pathways to poor birth outcomes in an urban Aboriginal birth cohort. Journal Paediatrics and Child Health 2008;44(6):342–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18476926

44. Freemantle J, Stanley F, Read A and de Klerk N. The first research report: patterns and trends in mortality of Western Australian infants, children and young people 1980-2002. Perth: Advisory Council on the Prevention of Deaths of Children and Young People, Department for Community Development, Government of Western Australia, 2004. Available from: http://www.ichr.uwa.edu.au/files/imce/ACPDCYP_report.pdf

45. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available from: http://www.surgeongeneral.gov/library/secondhandsmoke/


47. Eades S and Read A. Infant care practices in a metropolitan Aboriginal population: Bibbulung Gnarneep Team. Journal of Pediatric Child Health 1999;35(6):541–4. Available from: http://www3.interscience.wiley.com/journal/119096941/abstract?CRETRY=1&SRETRY=0

48. Wills R-A and Coory M. A preliminary look at the rates of cigarette smoking among mothers giving birth in Queensland. Information circular 77. Brisbane: Health Statistics Centre Queensland Government Department of Health, 2008. Available from: http://www.health.qld.gov.au/publications/infocirc/info77.pdf


50. Jacoby PA, Coates HL, Arumugaswamy A, Elsbury D, Stokes A, Monck R, et al. The effect of passive smoking on the risk of otitis media in Aboriginal and non-Aboriginal children in the Kalgoorlie-Boulder region of Western Australia. Medical Journal of Australia 2008;188(10):599–603. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18484936









http://www.australiandiabetescouncil.com/Resources/PDFs/NDSS-Information-Sheets/WHAT-IS-DIABETES-2010.aspx

http://www.australiandiabetescouncil.com/Resources/PDFs/NDSS-Information-Sheets/WHAT-IS-DIABETES-2010.aspx







http://www.mja.com.au/public/issues/190_10_180509/lew11058_fm.html

http://www.mja.com.au/public/issues/189_09_031108/wil10215_fm.pdf

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http://www.ichr.uwa.edu.au/files/imce/ACPDCYP_report.pdf

http://www.ichr.uwa.edu.au/files/imce/ACPDCYP_report.pdf

http://www.surgeongeneral.gov/library/secondhandsmoke


http://www3.interscience.wiley.com/journal/119096941/abstract?CRETRY=1&SRETRY=0

http://www3.interscience.wiley.com/journal/119096941/abstract?CRETRY=1&SRETRY=0

http://www.health.qld.gov.au/publications/infocirc/info77.pdf






8.8

Economic issues relating to tobacco use among Aboriginal peoples and Torres Straits IslandersSection 8.7 reviewed the serious health effects of tobacco use for Aboriginal peoples and Torres Strait Islanders, but tobacco also has an economic impact on these communities. Research undertaken by the National Aboriginal and Torres Strait Islander Tobacco Control Project in 2001 included information on the economic effects of tobacco use in a wide number of communities throughout Australia.1 This report found that expenditure on tobacco represented a significant proportion of family income among households with one or more smokers, and that purchases of tobacco were perceived as a priority, if necessary at the expense of food and other essentials. Tobacco consumption varied with stages in the pay cycle. As available funds declined, many reported using ‘chop-chop’ (unbranded loose ‘black market’ tobacco), or buying roll-your-own tobacco, cheaper cigarette brands and sharing packs. Some resorted to recycling cigarette butts into roll-your-own cigarettes. Smokers compensated for the lean times by smoking more heavily following pay day.1

Other research has confirmed that tobacco purchases are more likely to claim a disproportionate allocation of household expenditure in Indigenous households. One study in five remote central Australian communities estimated that between 12.7% and 9.1% of the maximum $453.30 per fortnight unemployment allowance for a single person was being spent on cigarettes.2 In a Northern Territory Indigenous community, cigarette purchases accounted for 22% of money spent in local retail outlets.3 Although the studies are not directly comparable, this is compared with the estimated 8% spent on tobacco products by households in the poorest income quintile nationally.4

The National Aboriginal and Torres Strait Islander Tobacco Control Project also found that pricing tobacco beyond the means of individual smokers did not tend to halt their access to the product, since the cultural obligation to share goods if requested means that it is likely that smokers who do have tobacco will be prevailed upon to share it. This in itself caused increased stress in some communities, interviewees reporting discomfort at high levels of ‘humbugging’ and ‘hassling’ for cigarettes or for the money with which to buy them. Young people put pressure on the elders to provide cigarettes, who in turn felt obliged to supply them. Some also reported episodes of coercion and intimidation. At worst, there have been reports of burglaries, violence and threats of self-harm in order to obtain tobacco.1 A study in remote communities in Central Australia has explained the relatively low consumption levels there in terms of access and cultural obligations to share. The remote location and limited store opening times limit access. Furthermore, the cultural obligation to share means that full packs are generally not exclusively smoked by the purchaser but are given to others. This obligatory sharing means that many smokers will not smoke large amounts of cigarettes, but it also means that smaller quantities of cigarettes are available to more people.2

The National Aboriginal and Torres Strait Islander Tobacco Control Project report concludes that in addition to health issues, tobacco use causes serious financial and social problems for many Aboriginal and Torres Strait Islander communities. It contributes to poor nutrition, especially in children, undermines family and community structures, and leads to concerns for personal safety.1 Increasing the price of tobacco through taxation has long been identified as an important and effective component of a comprehensive tobacco control program,5 and has almost certainly been an important contributing factor to declines in national smoking rates in Australia.6 There is evidence that increasing the price of tobacco does result in reduced prevalence even among the most disadvantaged in the community; in fact, rates are reduced more in low-income groups than middle- and high-income groups, thus reducing social disparities in smoking.7 The cost of cigarettes has been cited by Aboriginal peoples and Torres Strait Islanders as among the reasons why they quit smoking (see Section 8.6),1,8 and the National Aboriginal and Torres Strait Islander Tobacco Control Project report recommends further study into the impact of price increases on tobacco products as a means of tobacco control in the Indigenous populations.1 The impact of taxation on Indigenous smoking is discussed further in Section 8.10.14. Further initiatives addressing the economic impact of tobacco use on Indigenous communities are also discussed in Section 8.10: income management has been trialled in remote community stores (Section 8.10.10); and messages that emphasise the financial impact from smoking are being used by several communities in social marketing strategies (Section 8.10.11). Smoking and social disadvantage is discussed further in Chapter 9.



References1. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander Tobacco Control Project final report. Canberra: National Aboriginal Community Controlled Organisations,

2002. Available from: http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf

2. Butler R, Chapman S, Thomas DP and Torzillo P. Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities. Australian and New Zealand Journal of Public Health 2010;34(S1):S71–S75. Available from: http://dx.doi.org/10.1111/j.1753-6405.2010.00557.x


4. Siahpush M, Borland R and Scollo M. Smoking and financial stress. Tobacco Control 2003;12(1):60–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12612364

5. US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2000/index.htm

6. White V, Hill D, Siahpush M and Bobevski I. How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001. Tobacco Control 2003;12(suppl. 2):ii67–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12878776

7. Siahpush M, Wakefield M, Spittal MJ, Durkin SJ and Scollo MM. Taxation Reduces Social Disparities in Adult Smoking Prevalence. American Journal of Preventive Medicine 2009;36(4):285–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19201146



http://dx.doi.org/10.1111/j.1753-6405.2010.00557



http://www.cdc.gov/tobacco/data_statistics/sgr/2000/index.htm

http://www.cdc.gov/tobacco/data_statistics/sgr/2000/index.htm






8.9

Attitudes to and beliefs about smoking among Aboriginal peoples and Torres Strait Islanders8.9.1

Why do some Aboriginal peoples and Torres Strait Islanders smoke?The early sections of this chapter present a range of unique historical and socio-economic reasons contributing to higher rates of smoking among Aboriginal and Torres Strait Islander communities. There are a number of social and cultural factors that also contribute to maintaining high smoking rates in Aboriginal and Torres Strait Islander communities. The most influential of these are discussed further below: the role of smoking as an alleviator of stress, and the normative nature of smoking within these communities—socialising around the smoking activity and sharing tobacco are crucial in reinforcing relationships and maintaining social cohesion. These factors that motivate or maintain smoking behaviour, in turn become deterrents to quitting.

8.9.1.1

Smoking and stressStudies have reported that the most commonly cited reason for smoking is as a means of alleviating stress and as a way of signalling a few personal moments of ‘time out’.1–9 In this way, Aboriginal and Torres Strait Islander smokers are similar to non-Indigenous smokers, who also nominate stress relief as among the reasons they smoke.10 The Forgotten Smokers, a study of Indigenous smoking undertaken in 2000, found that respondents liked and valued smoking because unlike anything else in their lives, it reliably produced a relaxing and calming effect.2 However, the way stress is experienced by Indigenous people is profoundly different from the stress experience for many non-Indigenous people, and has implications for their smoking behaviour. Other than the stress caused by socio-economic conditions (e.g. low income, housing problems and unemployment), stressors cited in studies of Indigenous smokers include: family and work expectations and responsibilities; relationship problems and family violence; racism; and life-altering events, such as deaths in the (extended) family. 3–9 A study that followed the quit attempts of 32 smokers attending an Aboriginal health service found that the main barriers to achieving smoking cessation were the multiple and intercurrent life stressors that caused them to relapse.3 Several studies of pregnant Indigenous women have also found stress to be strongly associated with smoking; pregnant women have reported needing to smoke in order to relieve their stress, and seeing stressful events as triggers to relapse.4–7 The role of tobacco use in alleviating stress and negative feelings gives smoking value in communities experiencing high levels of daily hardship.

8.9.1.2

Smoking behaviour as a social normSeveral studies of the social context of Indigenous smoking reinforce the anecdotal evidence that strong social norms support smoking in Aboriginal and Torres Strait Islander communities.1,4,11 Smoking has been found to be a mechanism to maintain and strengthen kinship bonds and social relationships, and to enhance a sense of belonging and social cohesiveness. Social relationships are strengthened through the communal nature of smoking behaviour as well as through the exchange of cigarettes. The National Aboriginal and Torres Strait Islander Tobacco Control Project, through surveys and focus group discussions with community members and health staff across Australia, reported that the second most common reason cited for smoking was to be around other smokers. In



particular, sharing cigarettes was seen as a normal part of the culture, whereas non-smokers felt alienated from the group, partly because they were missing out on the sharing of ‘the best information’ and gossip.1 Family members who smoke have been found to be influential in the initiation to smoking and in maintaining smoking behaviour, although they can also be influential in quitting.11 Socialising over cigarettes has also been reported by Aboriginal health workers as a way of developing rapport with clients and of debriefing with work colleagues.1,12

Where smoking is commonplace, it serves as a way of identifying oneself with the group and enhancing social interactions. The special cultural connotations of tobacco use for Aboriginal and Torres Strait Islander communities strongly reinforce the behaviour. Within this setting, quit attempts are often undermined by others in the group1,2,4,12 and abstinence can result in a sense of exclusion. Several participants in one study on the social context of smoking reported being derided for their decision to quit, and felt that the only way to quit would be to distance themselves from their family.11 In a qualitative study in Western Australia, pregnant Indigenous women reported the difficulties they had quitting when their families, particularly partners, were not supportive, and when everyone around them was smoking.4 Having a partner who smokes, or living in a household with smokers, is significantly associated with Indigenous women smoking during pregnancy.5,13

8.9.1.3

Other reasons for smokingOther reasons for smoking that have been reported are as a way to relieve boredom, out of routine or habit (including when drinking alcohol, gambling or having a cup of tea or coffee), and addiction.1,2,4,6 Smoking has also been seen as an aid to weight loss (sometimes, ironically, in response to health advice to reduce weight due to other medical conditions such as diabetes or heart disease).1 One group interviewed reported that smoking was used as a way of curbing appetite, because they did not feel like cooking, or because there was no money for food.1 Projects with young people have also found that youth attitudes include smoking to look older, tougher or cool,14 and wanting to be like older children or parents.15

8.9.2

Why do some Aboriginal and Torres Strait Islander people not smoke?While smoking rates are high in Aboriginal and Torres Strait Islander communities, 53% of Aboriginal people and Torres Strait Islanders do not smoke, and 34% have never smoked.16 Very few studies have examined why some Aboriginal peoples and Torres Strait Islanders never take up smoking, but knowing this could be helpful in planning prevention activities. Young people in a study in Melbourne cited not wanting to be dependent on cigarettes, having seen harmful effects on the health of family members, and fearing that smoking would affect their fitness for sport.17 In another study in Maningrida, young people who did not smoke stated their main reasons as adverse effect on health, being too young, fear of getting into trouble, and not enjoying it.15 Non-smoking family role models and personal resilience and determination have been cited as influential in not taking up smoking.15,11 Other factors associated with reduced likelihood of initiation to smoking are discussed in Section 8.4.3.

The main reasons for quitting are health considerations, particularly considering both the direct and indirect impacts on the health and wellbeing of children. Other reasons include objections to the smell of the smoke (mainly from women) and the financial cost of buying cigarettes.2,4 The reasons why Aboriginal peoples and Torres Strait Islanders quit are detailed in Section 8.6.



8.9.3

Awareness of the health effects of smoking and secondhand smokeResearch has shown that Aboriginal and Torres Strait Islander communities have a good understanding of general health problems associated with smoking, but less knowledge of the specific harmful effects, though as with smoking prevalence there would be regional variation in levels of understanding. National research undertaken by the National Aboriginal and Torres Strait Islander Tobacco Control Project1 during 2001 found that more than 90% of respondents agreed that smoking was dangerous to health and caused a range of illnesses, including lung cancer, heart disease, emphysema and asthma, stroke and blood flow problems, blood pressure problems and problems in pregnancy. Knowledge was lower about the dangers of developing oral cancers and complications in diabetics.1 Studies involving pregnant Indigenous women have reported that they are aware of the general negative health impacts of smoking, but have limited knowledge of how smoking impacts on specific illnesses and on the health of the foetus.4,5,7 Similarly, a study of youth in Melbourne found that most were aware that smoking was bad for their health, but were not aware of the impacts on specific diseases.17 A small qualitative study of young people in Victoria found that 75% were aware of the ill effects of smoking, particularly the effects on their sporting performance.14 More than 60% of young people responding to a school-based survey knew about the effect of smoking on fitness and the heart, the risks associated with passive smoking, the relationship between smoking and lung cancer and respiratory symptoms, and the harmful effects of smoking to the health of adults. Fewer than 60% answered questions correctly about the contents of cigarettes, and the effect of smoking on life expectancy.15

While awareness of the health effects of smoking may generally be good, the National Aboriginal and Torres Strait Islander Tobacco Control Project report points out that a good understanding of the health dangers of smoking does not necessarily translate into quitting behaviour.1 The socio-economic and cultural factors that reinforce smoking in Indigenous communities may simply provide barriers that are too difficult to overcome. In one study of pregnant Indigenous women in New South Wales, around 75% of participants felt that quitting increased the chance of having a healthy baby, but 30% thought that quitting would be harder when pregnant, and 30% thought that there would be no point in quitting if they were exposed to a lot of environmental tobacco smoking anyway.18 Widespread self-exemption through a ‘she’ll be right’ attitude, coupled with the long latency period for many of the diseases caused by smoking, also affect attitudes to quitting.2

There was also a high awareness of the fact that secondhand smoke is dangerous to health, although communities involved in the National Aboriginal and Torres Strait Islander Tobacco Control Project gave mixed reports about whether it had instigated behavioural change. Levels of awareness were likely to be higher among those employed in workplaces that had introduced smokefree policies, but this only influenced those in employment.1 Ex-smokers in several studies report that the impact of smoking on others, particularly children, has motivated them to quit.2,11,14 Aboriginal health workers have reported that smokers are more likely to respond to cessation interventions that appeal to their desire to protect those around them, particularly children. They have also reported feeling more comfortable delivering these less confrontational messages.4,8 Given the high smoking rates among Indigenous people, it is probable that secondhand smoke is a serious contributor to ill-health, especially for children (see Section 8.7.4).

8.9.4

The relative importance of smoking as an issueAboriginal peoples and Torres Strait Islanders are impacted by such a large range of complex health and social issues that smoking often takes a lower priority both in the health service and broader community context.2,12 Indeed in one Western Australian study, Aboriginal health workers (n=36) ranked tobacco as the fourth ‘biggest problem’ (out of five options) behind diabetes, heart disease and alcohol, although they did classify it as a ‘serious’ or ‘very serious’ problem for their communities.19 People often attend at health services affected by acute social and health issues that need to be attended to first; health workers report being reluctant to provide smoking cessation advice in the context of so many competing and more immediate issues.4,20



In addition, while 75% of the respondents in the National Aboriginal and Torres Strait Islander Tobacco Control Project study believed that smoking was a big health problem,1 it was nonetheless relegated as a priority behind alcohol or illicit drugs, which present as a more immediate problem, both at community1,12 and service levels.1 Some individuals expressed the view that smoking was an acceptable alternative to other drug use.1 Other studies have also shown that tobacco is ranked behind alcohol and other drugs by Indigenous communities.2,12,21,22

Interestingly, the National Aboriginal and Torres Strait Islander Tobacco Control Project found that respondents tended to overestimate the prevalence of smoking in their communities. Given that the perception of high levels of smoking behaviour is seen as an impediment to quitting,1,12 there may be value in informing communities of the true prevalence of smoking, and that a significant number of Aboriginal peoples and Torres Strait Islanders choose not to smoke.1 Other recommendations supporting quitting activities are discussed in Section 8.10.



References1. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander Tobacco Control Project final report. Canberra: National Aboriginal Community Controlled Organisations,

2002. Available from: http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf

2. Stewart I and Wall S. The forgotten smokers. Aboriginal smoking: issues and responses. Commissioned by the Australian Medical Association and Australian Pharmaceutical Manufacturers’ Association. Canberra: Australian Medical Association, 2000. Available from: http://ama.com.au/node/778

3. DiGiacomo M, Davidson P, Davison J, Moore L and Abbott P. Stressful life events, resources and access: key considerations in quitting smoking at an Aboriginal Medical Service. Australian and New Zealand Journal of Public Health 2007;31(2):174-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17461010




7. Passey M, Gale J, Holt B, Leatherday C, Roberts C, Kay D, et al. Stop smoking in its tracks: understanding smoking by rural Aboriginal women, Conference paper. The 10th National Rural Health Conference. Cairns, Australia: National Rural Health Alliance, 2009. Available from: http://10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf



10. Carter S, Borland R and Chapman S. Finding the strength to kill your best friend: smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: http://old.tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf

11. Johnston V and Thomas D. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science & Medicine 2008;67(11):1708–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18938006



14. Alford K. Koori Community Smokescreen: cigarette use and attitudes in the Goulburn Valley. Aboriginal and Islander Health Worker Journal 2004;28(6):30–2. Available from: http://search.informit.com.au/documentSummary;dn=148038363859564;res=E-LIBRARY


16. Australian Bureau of Statistics. 4714.0 National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4714.02008?OpenDocument

17. Victorian Aboriginal Health Service. Cigarette Smoking. Study of Young People’s Health and Well-being. Fitzroy, Australia: VAHS, 1999.

18. Passey M, Gale J, Stirling J and Sanson-Fisher R. Tobacco, cannabis and alcohol: changes in pregnancy among Aboriginal women in NSW, Conference paper. Primary Health Care Research Conference. Darwin, Australia 2010: Adelaide: Flinders University Primary Health Care Research & Information Service, 2010. Available from: http://www.phcris.org.au/download.php?id=6874&spi=3

19. Pilkington A, Carter OBJ, Cameron AS and Thompson SC. Tobacco control practices among Aboriginal health professionals in Western Australia. Australian Journal of Primary Health 2009;15(2):152–8. Available from: http://www.publish.csiro.au/?paper=PY08066

20. Harvey D, Tsey K, Cadet-James Y, Minniecon D, Ivers R, McCalman J, et al. An evaluation of tobacco brief intervention training in three Indigenous health care settings in north Queensland. Australian and New Zealand Journal of Public Health 2002;26(5):426–31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12413286


22. Franks C. Gallinyalla: a town of substance? A descriptive study of alcohol, tobacco, medicines and other drug use in a rural setting. Rural and Remote Health 2006;6(2):491. Available from: http://www.rrh.org.au/publishedarticles/article_print_491.pdf


http://ama.com.au/node/778




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tobccamp_g.pdf









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http://www.rrh.org.au/publishedarticles/article_print_491.pdf



8.10

Tobacco action initiatives targeting Aboriginal peoples and Torres Straits IslandersAlthough health practitioners, community members and researchers have been working for many years to reduce tobacco use in Aboriginal and Torres Strait Islander communities, the delivery of tobacco action programs in these communities has until recently typically been marked by a lack of coordination and limited resources.1–8 Since 2008, with the announcement of the Tackling Indigenous Smoking Initiative, there has been a significant commitment to a strategic approach to Indigenous tobacco action with accompanying funding (see Section 8.13.5). Programs under this initiative are currently being rolled out. To date, critical evaluations of the various programs that have been undertaken among Aboriginal and Torres Strait Islander communities have been sparse; where they have been undertaken, they have been inhibited by small sample size and research design. While there is an extensive literature about tobacco (health promotion) initiatives aimed at reducing prevalence in other populations and their effectiveness, there is a paucity of evidence that considers the appropriateness and transferability of such initiatives to Aboriginal and Torres Strait Islander contexts.8–12 While there are still many questions of what constitutes best practice for cessation programs among Aboriginal and Torres Strait Islander communities, the increased action and funding in this area means that more information will become available over the coming years, as programs rolled out under the Tackling Indigenous Smoking Initiative are evaluated. Rigorous evaluations, particularly of secondary prevention programs and comprehensive community-wide programs, are needed to build the evidence base around tobacco action initiatives in Aboriginal and Torres Strait Islander communities.13

Despite the limited evidence around what works in Indigenous tobacco action, several reviews have identified the likely factors critical to the success of designing appropriate tobacco initiatives for Aboriginal and Torres Strait Islander communities.2,3,4,5,6,7,8,9,10,11,14 These reviews have considered existing programs that target Aboriginal peoples and Torres Strait Islanders, programs that work in the mainstream context, and programs with Indigenous people in other countries. A number of these documents have not only made recommendations on the types of programs needed, but have also detailed principles that should underpin tobacco action in Aboriginal and Torres Strait Islander communities to enhance program delivery.5,6,8,10,15,16 These principles include:

< maximising community control, and building capacity within Indigenous organisations and communities < understanding and respecting the social context in which Aboriginal peoples and Torres Strait Islanders live their lives, and ensuring that this is reflected in programs that include a focus on family and community

< developing programs that are holistic in nature and consider the social determinants of health < ensuring that tobacco action programs are as comprehensive as possible within given resources < evaluating all programs with a view to building the evidence of best practice in Indigenous tobacco action < making sufficient and ongoing funding available to develop sustainable long-term programs < building cooperative relationships across sectors, while always being mindful of maintaining Indigenous community control within these relationships.

This section will summarise the current evidence around successful tobacco action interventions in the Australian Indigenous context, and provide examples of programs and activities that have been (and are being) implemented in Aboriginal and Torres Strait Islander communities. The examples given are not exhaustive, but merely a sample; many people have been, and are currently, implementing programs in their communities. Readers interested in knowing more about particular programs in Aboriginal and Torres Strait Islander communities are referred to online resources that provide updated information on programs around the countryi.

i This includes the Project Register maintained by the Centre for Excellence in Indigenous Tobacco Control at www.ceitc.org.au/indigenous-projects-register and a listing of tobacco programs and projects at the Australian Indigenous HealthInfoNet at http://www.healthinfonet.ecu.edu.au/health-risks/tobacco/programs-projects

http://www.ceitc.org.au/indigenous-projects-register

http://www.healthinfonet.ecu.edu.au/health-risks/tobacco/programs-projects



8.10.1

Considering the context to develop relevant tobacco action programsIf smoking is understood as a ‘socially and culturally patterned behaviour’, then differences between Indigenous and non-Indigenous communities in history, social and cultural background and attitudes to health suggest that initiatives which have shown success elsewhere may not be transferable to Indigenous contexts without at least some degree of modification.12 In addition, the differences between various Aboriginal and Torres Strait Islander communities—urban, rural and remote—also militate against the success of a ‘one size fits all’ program for Indigenous communities. Tobacco action within Aboriginal and Torres Strait Islander communities must incorporate approaches that take into account the socio-economic realities of people’s lives and the unique social and cultural contexts, as well as considering how to overcome challenges within the healthcare delivery system that may contribute to reducing the effectiveness of tobacco action initiatives.

The impacts of socio-economic factors on smoking rates for Aboriginal peoples and Torres Strait Islanders have been discussed in Section 8.3. Clearly, tobacco action initiatives must take into account the underlying socio-economic realities facing many Indigenous people, and work towards addressing broader social disadvantage. However, it should be noted that the causal pathways between specific variables of socio-economic disadvantage (such as income, education, employment and housing) and smoking are not clear; the pathways are, in fact, likely to be highly complex and interconnected. Simply addressing one or another of these variables is unlikely to have an impact on smoking rates by itself.17

These socio-economic factors also contribute to the stressors that Aboriginal peoples and Torres Strait Islanders face in their daily lives; these stressors often occur together and repeatedly over time, thus magnifying their impact on individuals. Stress management is commonly given as a reason for smoking, and the cause of relapse after a quit attempt (see Section 8.9.1.1).18 This central role for tobacco use as a means of responding to stress must be recognised, and it has, therefore, been recommended that services ranging from simple counselling to the availability of more specialist programs on stress control be made available in conjunction with quit programs.15,18

Socio-economic factors alone are not, however, sufficient to be driving high rates of smoking in Aboriginal and Torres Strait Islander communities. Indeed, even among Indigenous people in the highest quintile of household income, smoking rates are still at 37%.17 Clearly, social and cultural factors, such as the social normalisation of smoking, reinforced by the social obligations to exchange and share tobacco as a means of reinforcing social relationships and social cohesion, are also important19 (see Section 8.9.1.2). The influence of extended family relationships in the uptake and maintenance of smoking, as well as in quitting, leads logically to the suggestion that family-centred initiatives based in the home and community should be part of tobacco action programs in Indigenous communities.19 In addition, respect for elders and older community members means that they may be influential role models, particularly for other adults. Harnessing the support of older smokers and supporting them to quit may contribute to initiating more widespread declines in smoking behaviour.20

Many prevention and cessation programs that have been successful in the mainstream context have failed to make significant impacts in Indigenous communities, and the reasons for this are complex. Some argue that mainstream public health messages lack relevance for many Indigenous people and suggest the need for culturally relevant messages and programs.12,20,21 Several studies suggest, however, that many mainstream tobacco action activities are acceptable to and effective for Aboriginal peoples and Torres Strait Islanders (see Section 8.10.11).12,22 While modifications of programs are clearly important, the role of the health system in reducing the effectiveness of tobacco action programs should not be overlooked.12 Barriers in the health system that can impact on program efficacy include: workforce turnover; lack of staff training opportunities; the orientation of services towards acute rather than preventive care; and even, simply, access to and availability of appropriate health services and treatment for Indigenous people (see sections 8.10.4 and 8.10.5). Adequate and sustained funding to the healthcare system specifically for Indigenous people and specifically directed towards tobacco action has also been cited as necessary for program success.5,8,23



8.10.2

Taking a comprehensive approachComprehensive tobacco action programs that are likely to have the greatest success in Aboriginal and Torres Strait Islander communities are multi-component, take a whole-of-community approach, are integrated across different activities within health services, and work across different sectors within communities. In mainstream programs, it is well understood that addressing one part of tobacco control in isolation reduces the chances of success.24 For example, the benefits of producing salient health messages are diminished if appropriate training for health staff to provide further information and support quitting is not provided. Offering access to pharmacological aids to cessation in the absence of creating a supportive structure in which cessation can occur is similarly unlikely to succeed.24 It is likely that a cumulative effect of exposure to low-level or indirect anti-tobacco activities delivered as part of a comprehensive tobacco action program (such as brief interventions and anti-tobacco advertising) may have an impact on Indigenous smokers quitting by themselves; some studies have noted high levels of Indigenous smokers who have quit without the use of organised programs or specific help.25,26 This underscores the value of taking a comprehensive approach. The basic components of a comprehensive tobacco-control program, as outlined in the Introduction to this book, include education, restrictions on access, bans on advertising and promotion, and taxation increases.24

It is also important not to treat tobacco use in isolation. Strategies intended to reduce smoking rates will not be effective if planned without reference to community-identified health priorities such as alcohol and other drug misuse, violence, education and employment. As with other disadvantaged groups within the general population, raising standards of living and improving educational and employment opportunities can be expected to enhance overall health outcomes, as well as bringing about declines in smoking. Tobacco interventions need to be part of a multi-level approach that recognises the broader social, economic and cultural environment of communities.27

Such multi-level, comprehensive approaches are consistent with the principles of Indigenous community-controlled primary healthcare and with a holistic view of health. This concept, where health is ‘not just the physical well-being of the individual, but the social, emotional and cultural well-being of the whole community’,28 and that all things—community, land, mind and spirit, the physical and spiritual—are interconnected and interdependent, means that consideration of one element cannot meaningfully occur in isolation from the others.29 This world view underpins the delivery of healthcare by Aboriginal Community Controlled Health Organisations that ideally focus on comprehensive, integrated and preventive approaches within a framework of community control and self-determination.30 Like other health activities within these services, tobacco action activities, that are integrated across other health and social programs areas (such as chronic disease programs and women’s and children’s programs), and have systems and protocols put in place to ensure coordinated care of patients, are likely to provide the best outcomes for Indigenous communities.

Many multi-component tobacco action programs have been, or are currently being, implemented in Aboriginal Community Controlled Health Organisations and in Aboriginal and Torres Strait Islander communities. These include: the Tobacco Project;31,32 the Top End Tobacco Project (Northern Territory);33–36 Clean Air Dreaming (New South Wales);37 Building Research Evidence to address Aboriginal Tobacco Habits Effectively (BREATHE),38 and Tobacco Resistance and Control (A-TRAC) Program (Aboriginal Health and Medical Research Council of New South Wales);39 Our Space Smoke Free (Queensland);40 Deadly Nungas Say No to Puiya (South Australia);41,42 Northern Territory Tobacco Project;23 Goreen Narrkwarren Ngrn-toura (Healthy Family Air) (Victoria);7,43 Stop Smoking in its Tracks (New South Wales);44 Beyond the Big Smoke (Western Australia);45,46 Be Our Ally Beat Smoking (Western Australia);47 Reducing Aboriginal Children’s Tobacco Exposure in the Pilbara;48 The Smokers Program (Maari Ma Health Aboriginal Corporation—New South Wales); 49 Bila Muuji Smoking Cessation Project (New South Wales);50 No Smokes North Coast (New South Wales);51 and tobacco-control programs at Miwatj Health Aboriginal Corporation,52 Kimberley Aboriginal Medical Services Corporation,53 and the Tasmanian Aboriginal Corporation,54 This list is not exhaustive, and there are many other organisations working on tobacco action projects (see footnote i).

These projects include a selection of the following components: < brief interventions < specialised tobacco action workforce



< training for the workforce (both specialised and general) in tobacco action, including in brief intervention < pharmacological assistance—nicotine replacement therapies, bupropion, and varenicline < hospital cessation programs < referral to quitlines < quit support groups < health education activities—including education sessions, DVDs, websites < social marketing campaigns, including television, radio, print, posters, pamphlets, the internet and mobile phones

< sponsorship of cultural, sporting and community events < outreach-style programs, such as family-centred home-visit-based programs < programs to reduce exposure to environmental tobacco smoking in the home and/or car < development and implementation of smokefree workplace policies < programs to support specific sub-populations to quit—Aboriginal health workers, pregnant women, prison inmates

< prevention programs with youth and children < incentive-based programs to encourage cessation < broad state/territory and Commonwealth legislation.

Many of the multi-component tobacco action programs listed above are not yet evaluated as they are only recently underway; others have been evaluated, but are not yet published. Published evaluations of multi-component projects in the Northern Territory23,31,32 and North Queensland55 have found no measureable impact on smoking cessation, although one of the Northern Territory studies (The Tobacco Action Project, 1999–2000) found increases in knowledge of the health effects of tobacco and readiness to quit.32 This study and the other Northern Territory study (The Tobacco Project, 2007–08) also found that those communities with the most tobacco action activity measured the greatest decline in tobacco consumption.23,32 Importantly, the evaluation of The North Queensland Indigenous Tobacco Project found that health services and communities felt that they had minimal ownership and input into the project, and this may have affected the limited overall impact that the program had.55 The success of community-based multi-component programs relies on community ownership, and involvement in the development, implementation and evaluation of these programs.8

A project at the Maari Ma Health Aboriginal Corporation that has been evaluated involves running a Smoker’s Program to provide an intensive 12-week support program with a case manager and an individualised management plan (including nicotine replacement therapy and other pharmacotherapies, counselling support, referral to quitline and ongoing support).49 This program is delivered in the context of other health service activities such as brief intervention training for all staff (even non-clinical staff), and the implementation of smokefree workplace policies. Within the context of these other activities, the Smoker’s Program appears to have been successful at promoting quit attempts among participants; 16.3% of Aboriginal people who had ever participated in the Smoker’s Program (up to June 2009) had a ‘quit’ status at 12 months after entering the program.49 This project is being extended, building on the current Smoker’s Program, to include strategies to engage young people and pregnant women in smoking cessation.56

8.10.3

Harm reduction approachesRoche and Ober have argued that adoption of harm reduction strategies might usefully increase the range of initiatives open to health workers in Aboriginal and Torres Strait Islander communities.57 Harm reduction places a priority on limiting damage caused by tobacco use, rather than making cessation the primary goal. In societies where tobacco use is endemic and barriers to quitting complex, it may that the pragmatic approach offered by harm reduction is more likely to deliver measurable health benefits. Cutting down on the number of cigarettes has been reported by Indigenous smokers, particularly in studies of pregnant smokers, as a conscious strategy to reduce tobacco-related harm.58,59



Elements of harm reduction in relation to tobacco use might include increasing ease of access to treatment, encouraging lower levels of consumption, protecting non-smokers (e.g. by introducing smokefree areas), and monitoring for early signs of smoking-related illness.57 Roche and Ober contend that given the damage tobacco causes among Aboriginal and Torres Strait Islander communities, it is likely that any potential gains accruing from adoption of a harm minimisation approach would outweigh possible disadvantages. However they underline the need for monitoring and evaluation of any strategies, particularly the importance of allowing particular communities to develop their own programs.

The concept of harm reduction in relation to tobacco use is discussed in greater detail in Chapter 16.

8.10.4

Roles of health servicesSmoking cessation activities are available to Aboriginal peoples and Torres Strait Islanders through a variety of health service contexts: Aboriginal community controlled health services, pharmacies, and general practitioners in community or government health services and private practice. Recent developments in Aboriginal health policy and funding have been strategically directed within these sectors to address chronic diseases and risk factors such as smoking.60,61

Many Indigenous people access healthcare primarily through Aboriginal community controlled health services. These organisations are largely governed and managed by Indigenous people from the local community, and employ Aboriginal health workers to assist in the delivery of holistic, comprehensive and culturally relevant healthcare. The components of service delivery are determined by the health needs of the local community and the capacities of the organisations. They often include more than just general practice healthcare; they may also include services such as: maternal and child health services; services for social and emotional wellbeing; health promotion and public health programs; health screening programs; and welfare services, such as housing or financial counselling.62 There is enormous variation in the sizes, ranges of services offered and capacities of Aboriginal community controlled health services.

Aboriginal community controlled health services have an important role to play in implementing smoking cessation activities for Aboriginal peoples and Torres Strait Islanders, but the nature of these activities, and their capacities to deliver them, vary from location to location. Smoking cessation programs may include: clinical level activities such as brief interventions, nicotine replacement therapy provision and support programs; and preventive activities within the health services, such as health education, social marketing and the development of supportive workplace policies. Staff from Aboriginal community controlled health services may also become involved with supporting broader community-level initiatives, such as policies around smokefree community areas, or programs delivered through schools, stores or other organisations. Many health services are also specifically implementing programs and activities to support their staff to quit smoking (see Section 8.10.13.1).

A number of studies have documented the service capacity issues faced in delivering tobacco-control programs within Aboriginal community controlled health services.12,27,58,63,23 For many health services it has been difficult to prioritise tobacco control as there are so many other competing and immediate health and social issues; service delivery often places a disproportionate focus on acute biomedical healthcare rather than on preventive healthcare.12,27,63 Within this context, some health workers report that there is not enough time to build relationships with patients that are sufficiently robust to enable them to raise what they see as sensitive and confronting lifestyle issues (such as smoking).63 Health service staff involved in one study suggested adult health checks as an enabler to conducting brief interventions, but several services in this study had found it difficult to incorporate adult health checks into their work practice.63 In another study, taking a team approach to healthcare delivery, and the development of an effective chronic disease program that included dedicated health promotion positions, were enablers to the delivery of tobacco brief interventions.12 Other service capacity issues include: the capacity (particularly time and resources) to provide and support adequate training;12,63 high staff turnover and difficulty retaining skilled staff;23,27,63 inadequate resourcing to sustain activities;23 lack of infrastructure to adequately provide programs;63 and lack of follow-up services to which to refer patients.58 Strong and consistent leadership was also recognised as an enabler.63 One study found that where the community is ‘ready’ to respond to smoking—i.e.



tobacco control has been identified as a priority, key stakeholders are mobilised, and staff have been made available to implement activities—tobacco-control activity is more likely to occur.23

While Aboriginal community controlled health services are central in the delivery of healthcare to Aboriginal peoples and Torres Strait Islanders, many Indigenous people will, whether by necessity or choice, access mainstream services—i.e. those without Indigenous structures of governance. Access to such services may be limited by factors such as cost, reduced cultural safety, language barriers, and racism (whether perceived or actual). It is crucial that mainstream services are well equipped, through appropriate training and funding, and through the establishment of referral relationships, to work with Aboriginal and Torres Strait Islander clients. General practitioners in community health clinics or private practice require additional support to ensure both adequate identification of Indigenous patients and appropriate management of their health concerns. For example, the Practice Incentives Programs Indigenous Health Incentive provides financial incentives for general practices to manage complex chronic disease issues for Indigenous patients, and the Pharmaceutical Benefits Scheme Co-payment Measure enables the prescription of medications (including nicotine replacement therapy and other pharmacotherapies) for the prevention or management of chronic diseases.64 Hospitals can also provide support to Indigenous inpatients who have been identified as smokers, for instance by informing them of the hospital’s smokefree policy, advising and supporting them with options for managing nicotine withdrawal during their stay, and offering them further support after discharge.65 High-intensity cessation support has been found to result in higher quit rates in other populations,66 and could also be successful for Aboriginal peoples and Torres Strait Islanders.9

8.10.5

Roles of Aboriginal health workersAboriginal health workers are critical to the delivery of primary healthcare interventions and therefore play an important role in addressing smoking in communities. However, they face very particular challenges in delivering tobacco action activities. They often come from and reside in the communities where they work.67 Since they are part of the same social context as their client base, it is not surprising that they also have comparatively high smoking rates (see Section 8.3.4). The nature of the work and the workload is also stressful, given that they are immersed in communities with high health and welfare needs, operate within time and resources constraints, and have specific social expectations placed upon them by family and community members.68 The stressful nature of their work makes it more difficult for Aboriginal health workers who smoke to quit themselves, and also provides a challenging work environment within which to deliver smoking cessation activities.

Studies report varying rates of Aboriginal health workers asking clients about their smoking status and talking to clients about cessation. One Western Australian study of 36 Aboriginal health workers reported that one-third asked all of their clients if they smoked, but just over a quarter asked none.69 In a New South Wales study involving 98 Aboriginal health workers, 80% reported providing quit smoking advice in their professional capacity.70 However, while most Aboriginal health workers in a qualitative study in Western Australia (n=10) reported routinely asking their pregnant clients if they smoked, very few followed this up with specific cessation advice.58 Another study with Indigenous pregnant women found that while most had been asked by a health worker during their antenatal care if they smoked (95%), fewer had been given advice to stop smoking (83%), and even fewer had been offered support to stop smoking (65%).71 The National Aboriginal and Torres Strait Islander Tobacco Control Project also found that fewer than half of surveyed health staff reported that they had discussed tobacco with clients.15

Aboriginal health workers face a range of barriers that impact on their capacities to provide smoking cessation advice, which include high prevalence rates, community attitudes to smoking, and their levels of confidence, knowledge and skills to deliver tobacco-control activities. The lower relative priority of smoking when compared to other more urgent health and social issues affecting clients’ lives (including from other more immediately damaging alcohol and drug misuse) impacts on the priority that health workers can place on smoking cessation in the clinical context, and their capacity to undertake preventive activities in tobacco control.27,58,70 Looking from the perspective of the client rather than the health worker, The Forgotten Smokers reported that smokers felt they had limited access to health workers, and that health workers were generally too busy caring for people with acute



health problems to have the time to talk about smoking.72 The need for a specialised tobacco action workforce is widely recognised as a way to improve the capacity of services to deliver tobacco action activities,5,73,12 and forms the backbone of the response under the Tackling Indigenous Smoking Initiative.61

There is a consistent view across various geographical settings that high rates of smoking among Aboriginal health workers may impact on their confidence and capacity to offer smoking cessation advice to their clients.20,27,67,69,70,74 Smoking among health workers could have an impact in the following ways: it reduces the importance of smoking as a problem to be dealt with immediately (in the context of other pressing concerns); health workers who smoke do not feel they have the right to advise others to quit; any quit message coming from them may lack credibility; and if they themselves try to quit and fail, this proves that quitting is too hard to attempt.20 A 2011 review of studies involving Aboriginal health workers found that Aboriginal health workers’ own smoking status may be a barrier to them providing smoking cessation support or tobacco-control activities. However, the limited number of studies available, the small sample sizes, and differences in methodologies and participant groups makes it difficult to draw firm conclusions.67 A Western Australian study reported that compared with Aboriginal health workers who currently smoke, Aboriginal health workers who are non-smokers and ex-smokers are more likely to advise smokers to quit and to provide warnings about the detrimental health effects of smoking, although the numbers in the study were low (n=36).69 A study in three Northern Territory ‘Top End’ communities published in 2010 found that around three-quarters of health workers (25 of 31) and Aboriginal health workers (13 of 17)—both smokers and non-smokers—reported that Aboriginal health workers’ smoking status is a barrier to providing cessation advice to clients.74 Their main concern was for the credibility of the health workers; if they could not quit themselves, how could they talk to others about cessation? Aboriginal health workers reported that if they could quit themselves, they might feel more confident speaking to community members about smoking cessation. Participants suggested that Aboriginal health workers could feel more comfortable delivering smoking cessation advice if they had adequate and appropriate training, and support in the workplace to quit, such as nicotine replacement therapy, quit groups and quit buddies.74 On the other hand, research from New South Wales has shown that some health workers who were non-smokers also felt uncomfortable discussing smoking, since they lacked personal experience of tobacco addiction and making quit attempts.70 Another study in Western Australia reported that two non-smoking Aboriginal health workers (of 36 total participants) felt uncomfortable talking to clients about cessation as they worked with colleagues who smoked and so did not want to appear hypocritical by association.69

Aboriginal health workers (whether smokers or non-smokers) have expressed concern that discussing smoking cessation could be perceived by their clients as judgmental and moralising.27,58,69,75 Health workers have reported being concerned about making their clients feel badly about themselves by raising smoking cessation, particularly when so many other health and social issues are affecting them.27,58 Some Aboriginal health workers have reported discomfort at providing smoking cessation advice to elders or respected family members,12,27,69,76 and some are also worried that raising smoking will damage the therapeutic relationship and discourage patients from returning for ongoing healthcare.58,63 They have reported attenuating this discomfort by using less confrontational strategies for talking to people about smoking, including speaking about the general effects or talking about reducing passive smoking around children.58 However, while Aboriginal health workers have these concerns, their clients do not necessarily agree. One study with pregnant Indigenous women in New South Wales found that 80% of the women thought that healthcare workers should tell pregnant women to quit.71

Studies and workshops examining workforce issues in Indigenous tobacco control cite lack of knowledge, skills and training as other reasons for not providing information to promote quitting.4,15,27,41,69,70,72,75,77–80 While smoking is part of the competencies in Aboriginal health worker training, how this is actually taught varies from provider to provider. A survey of training providers found that most taught general information about tobacco use, but few provided skills-based training in facilitating quit groups or in using nicotine replacement therapy. Additional resources were needed for both Aboriginal health workers and the trainers.79 Another study supports this finding that training should cover more than simply brief interventions, and include information about addiction, motivational interviewing and the use of pharmacotherapies.69 Indigenous-specific packages to deliver brief intervention training have been developed (see Section 8.10.6), and other training packages have been developed around the country. For example, the Centre for Excellence in Indigenous Tobacco Control has developed a Talkin’ Up Good Air kit80 to improve knowledge and expertise on the development of tobacco programs within Indigenous communities, and training in the use of this package is being rolled out around the country.



8.10.6

Brief interventions and brief intervention trainingBrief interventions delivered by health professionals have been found to be effective in reducing smoking prevalence in various mainstream settings,81–83 and are quick, inexpensive and non-invasive to deliver.8 There have been no studies specifically evaluating the efficacy of brief interventions delivered to Aboriginal peoples and Torres Strait Islanders, particularly when delivered by Aboriginal health workers. A number of evaluations have included brief interventions or individual counselling as part of the overall delivery of treatment,25,55 but it is difficult to assess the contribution of brief interventions to cessation rates. A qualitative study involving interviews with 25 residents of remote Northern Territory communities reported that for those with a smoking history (15 current smokers, six ex-smokers, two recently quit smokers) brief interventions from Aboriginal health workers were influential in their decision to quit, particularly when provided in the context of acute health events.12

In mainstream settings, training health professionals in providing smoking brief interventions has been shown to have a measurable effect on their professional practice; they are more likely to identify smokers and to provide them with smoking cessation advice than untrained professionals. However, there is no strong evidence that this then translates into more people quitting smoking.84

In the Indigenous contexts, training programs such as SmokeCheck have been rolled out in several states to address the lack of skills and confidence that health workers face in delivering smoking cessation advice and tobacco programs. SmokeCheck has been adopted in Queensland, New South Wales, South Australia and Western Australia, and evaluated in Queensland and New South Wales.75,85 The evaluation of the New South Wales SmokeCheck program found that there were significant increases in the confidence of health workers to talk to their clients about the health effects of smoking, raise ‘quitting’ with clients making health visits for unrelated reasons, assess clients’ stage of change for smoking cessation/readiness to quit, and raise smoking as a point of discussion with clients. In addition, there were increases in the number of health workers who provided advice about nicotine replacement therapy, environmental tobacco smoke, and cutting down tobacco use. More Aboriginal health workers recognised the importance of offering smoking cessation advice to their clients after the training, and perceived that it was easier to offer this advice after having received the training. The number of Aboriginal health workers living in smokefree homes increased during the project, as did the availability of culturally appropriate written resources to support clients to quit.85 Similarly, evaluations of the use of SmokeCheck in Queensland27,55,75 found that health workers were satisfied with the training, that it increased their confidence to deliver smoking cessation advice appropriately, and that it improved their clinical practice.

While SmokeCheck training can result in improvements in clinical practice, and may have benefits for practitioners who smoke, its impact on improving smoking cessation rates for patients is not yet clear. One study of the South Australian SmokeCheck program that has followed up clients at three and six months appears to have encouraged quit attempts, but the numbers are too small to make definitive statements about the success of this program 86. In a study evaluating the impact of a SmokeCheck pilot program in Queensland, there was no evidence that any patients or practitioners had given up smoking after six months.27

Quit Victoria has also been involved in developing and delivering educator training to Indigenous communities in Victoria and the Northern Territory. This two-day training program provides general information and brief intervention training, and notably presents this in an interactive way to promote participants to think about and problem solve the challenging situations in which they may find themselves.76 While the program may be successful in improving health worker confidence to talk to clients about smoking cessation, the impact on actual smoking rates, as with the SmokeCheck program, is not known.



8.10.7

Pharmacological assistance: nicotine replacement therapies, bupropion (Zyban) and varenicline (Champix)There is evidence in other populations that nicotine replacement therapies, bupropion (Zyban) and varenicline (Champix) are effective at increasing the likelihood of cessation success (see Chapter 7).87–89 A review of studies in the US found that nicotine patches or bupropion were effective at helping African American smokers to quit,90 and a study involving Māori smokers found that bupropion was an effective treatment for smoking cessation.91

Only a small number of studies have examined the use of nicotine replacement therapies and/or bupropion among Indigenous Australians, and have found success rates between 6–19%—in New South Wales (two studies),18,92

Queensland (one study),55 Northern Territory (one study)25 and Victoria (one study)93. The sample sizes of most of these studies have been small, and none has been a randomised controlled trial. All have combined nicotine replacement therapy and/or bupropion with brief intervention and/or some kind of ongoing counselling or support. Although the quit rates are lower than those reported for other populations in the medical literature,87 these studies provide evidence that assisted availability of nicotine replacement therapy, in combination with appropriate cessation support counselling, could benefit some Indigenous smokers. Several studies challenge the common perception that Indigenous people tend to be heavy smokers, and suggest that nicotine replacement therapy prescription should not assume that Indigenous smokers are necessarily heavily addicted. These studies have found low levels of nicotine addiction in some communities or sub-populations (measured by daily consumption based on store sales,94–96 or on the Fagerström Test for Nicotine Dependence97,98) for whom nicotine replacement therapy prescription would not necessarily be appropriate.

Two studies have investigated attitudes to nicotine replacement therapy and other pharmacotherapies, and issues around their prescription. In 2001, the National Aboriginal and Torres Strait Islander Tobacco Control Project spoke to 275 Aboriginal people and Torres Strait Islanders around the country and reported a high awareness of the existence of pharmacological aids to quitting smoking, and particularly of nicotine replacement therapy. However, a lack of factual information had led to a wide range of misconceptions and misunderstandings about the nature of these products and how they worked.15 Similarly, a study in six remote Northern Territory communities involving 25 community members and 19 health staff reported that knowledge about how nicotine replacement therapy works to help people to quit is low.12 Among the obstacles to access cited in these studies are: limited availability in some communities—nicotine replacement therapy is not routinely stocked, and there is a long delay between ordering and delivery of these medications;12 health staff report a lack of knowledge and confidence in prescribing;12 poor patient compliance—patients would not return for new supplies, or would run out after sharing their nicotine replacement therapy with other family members;12 and cost.12,15 Activities that are likely to improve the success of nicotine replacement therapy in helping Indigenous smokers to quit are: providing better information to patients and the community;12,15 providing nicotine replacement therapy as part of a comprehensive tobacco cessation program;15 providing ongoing support and counselling to patients through regular face-to-face meetings;12 and providing nicotine replacement therapy free of charge to Indigenous smokers wanting to quit.12,15,72

Since December 2008, nicotine patches have been available to Aboriginal and Torres Strait Islander patients at a subsidised cost on an authority script through the Pharmaceutical Benefits Scheme (PBS).99 However, since July 2010 nicotine patches and other pharmacotherapies have become available to Aboriginal and Torres Strait Islander patients on an authority script for no cost to healthcare cardholders and at the concessional rate for others. This is available as part of the PBS co-payment measure of the Practice Incentives Program Indigenous Health Incentive to services that are accredited against the Royal Australian College of General Practitioners standards.64 While nicotine replacement therapy and other pharmacotherapies may become more available under this measure, they will not necessarily be more accessible; many of the barriers to accessing mainstream health services faced by some Indigenous people (such as cultural safety, language and racism—see Section 8.10.4) will remain. Other issues with the implementation of this incentive have also been raised, including the relatively lower rates of accreditation of Aboriginal community controlled health organisations;100 in 2008–09, 35% of the 130 Aboriginal and Torres Strait Islander primary healthcare services that employed a general practitioner would have been ineligible for the incentive as they were not accredited.101



8.10.8

QuitlinesQuitlines when used as a component of anti-smoking campaigns have been found to be cost effective in improving quit rates, particularly when multiple calls are made.102 Utilisation and effectiveness of quitlines have not been specifically evaluated for Aboriginal peoples and Torres Strait Islanders;8 anecdotally usage is low. There is international evidence that quitlines can be acceptable to and effective for Indigenous peoples.103–106 Studies have shown that quitline services may be enhanced for Indigenous people through cultural awareness and competency training of staff,103 the availability of Indigenous quitline counsellors,104 the provision of nicotine replacement therapy in conjunction with telephone counselling,103,104 and when broader anti smoking campaigns are targeted to culturally specific groups.106 The acceptability, accessibility and success of quitlines for Aboriginal peoples and Torres Strait Islanders needs to be assessed. One study in an Aboriginal health service in Victoria noted that, with encouragement, apprehension to receive support through quitlines was overcome, and that the quitline was well liked and potentially useful.93 However, quitlines are likely to be inappropriate and inaccessible for Indigenous people who live in remote or very remote areas, due to language barriers and access to the use of a phone. Improving access to and appropriateness of quitlines is one of the activities of the Tackling Indigenous Smoking Initiative (see Section 8.13.5).61

8.10.9

Quit support groups and rehabilitation-style programsWhile individually based interventions may work best for some, research also highlights the possible advantages of establishing support groups for those who want to quit smoking, particularly older smokers who find it difficult to resist the smoking behaviour of their peer group. These groups, preferably lead by an Indigenous ex-smoker and perhaps open only to Indigenous people, would build upon sense of community and be likely to increase the success of quit attempts.20,72 The concept of rehabilitation-style programs, like those offered for alcohol and other drug withdrawal, has also been raised as a possibility.15

There has been limited evaluation of mainstream quit programs for Aboriginal peoples and Torres Strait Islanders, though two studies point to the potential of quit programs delivered as part of a more comprehensive approach and when modified to meet the needs of Aboriginal and Torres Strait Islander communities.12,93 A short course delivered in group sessions over a three-week period by an Aboriginal medical service in a rural community in Victoria achieved a 19% quit rate (6 of 32 participants). However the course was part of a multi-component community intervention that included brief cessation advice, nicotine replacement therapy, ongoing support from Quitline and the quit facilitator and an individually tailored management plan that involved a range of health professionals93. Health and welfare staff (n=19) working in remote Northern Territory communities reported that programs that are unmodified from the mainstream content and delivery mode are inappropriate for this setting. The course and materials should not only be translated appropriately, but the concepts in the program need to be ‘translated’ into an Indigenous worldview. In one community, staff had adjusted the group program to be delivered informally to family groups within their homes, rather than to mixed groups at a central location.12

8.10.10

Role of remote community shopsAs part of the 1999–2000 evaluation of a Northern Territory tobacco action project, researchers assessed the potential role of remote community stores to be involved in health promotion programs around tobacco action. Findings from the study suggest that community shops serving remote communities may potentially assist in tobacco control by supporting community tobacco action programs, through displaying or providing anti-tobacco health promotion materials, implementing smokefree policies, and providing staff with training to deliver cessation advice. Pricing policies adopted by community stores may also have an impact on tobacco sales, although this is an area requiring further research and assessment.107 One study examined trends in monthly sales to examine the



impact of the income management on sales of products including tobacco and cigarettes in 10 remote Indigenous communities in the 18 months before and after the introduction of the Northern Territory Emergency Response. Income management strategies restrict the purchase of certain products, including cigarettes and tobacco, aiming to encourage the sale of healthy food. Under the Northern Territory Emergency Response, this was administered through the use of a card that electronically restricted the purchase of certain items such as cigarettes and tobacco. The study found no beneficial effect in terms of sustained change in the sales of healthy food, soft drink or tobacco resulting from the strategy. It did, however, find that there was a marked increase in all store sales with the government stimulus package. These findings suggest that income management alone will not lead to modification of spending patterns.108

8.10.11

Social marketingMainstream social marketing campaigns, when well funded and sustained over time, have been effective at reducing smoking prevalence.109 However, there is relatively little information available on the impact of mainstream media campaigns on Aboriginal peoples and Torres Strait Islanders. Only three evaluations have been undertaken—two on the impact of the National Tobacco Campaign (in Victoria20 and remote Northern Territory communities110), and one on the Bubblewrap campaign in metropolitan and regional towns of Western Australia.111 The evaluations of the National Tobacco Campaign found that recall of these advertisements was high, but that there was little effect on quitting attempts or on smoking cessation rates.20,110 A 2008 evaluation of the impact of the Bubblewrap campaign on 198 Indigenous smokers in Western Australia also found high rates of recall. In addition, the advertisements were judged to be believable and relevant by the majority of participants, and most had thought about cutting down the amount they smoked (81%) and/or quitting (68%) as a result of seeing these advertisements.111 Similarly, a qualitative study involving interviews with 25 community members and 19 health service staff in remote Northern Territory communities reported good recall of mainstream anti-tobacco media messages, especially those using graphic imagery.12 These findings have been replicated in a study involving 143 Indigenous and 156 non-Indigenous people who were asked to rate mainstream anti-tobacco advertisements on a scale that included message acceptance and personalised effectiveness. Indigenous people rated the mainstream advertisements higher than non-Indigenous people, and found advertisements with strong graphic imagery depicting emotive first-person narratives about the health effects of smoking particularly motivating. These findings suggest that Aboriginal and Torres Strait Islander smokers may be positively influenced by mainstream anti-smoking mass media campaigns, and that this could be a cost-effective way of impacting on smoking rates.22

Several studies have documented the concerns of Indigenous people about the acceptability and efficacy of mainstream media campaigns, and discuss the need to improve the cultural and social relevance of advertisements for Indigenous people.12,20,21,72 One project in metropolitan and rural communities in Victoria documented that while older Indigenous people and Indigenous health workers believed that printed materials needed to be Indigenous specific or contain Indigenous content, many young people in the study did not necessarily agree; they reported being more likely to identify with the broader youth culture than with Indigenous culture, and commented that it made no difference to them if they were given Indigenous-specific materials.20

There have, over the years, been a number of examples of Indigenous-specific tobacco-related social marketing campaigns or projects. These generally take the form of an Indigenous component of a mainstream campaign or program (for example, posters or advertisements with Indigenous slogans or Indigenous people on them),112 113,114 115 or form a component of a multi-faceted tobacco-control program.48 ,116–118 No examples of formal evaluation of Indigenous-specific social marketing products have been located. In New Zealand, an anti-smoking campaign for Māori used the slogan ‘it’s about whānau’ (‘it’s about extended family’) and depicted testimonials from Māori smokers and whānau of ex-smokers; the focus was on immediate social consequences of smoking rather than future health consequences. The campaign was successfully recalled by smokers and their whānau one year after its launch, the advertisements were consistently rated as very believable or very relevant by over half of the smokers who had seen them, calls to the Quitline increased, and 54% of the smokers stated that the campaign had made them more likely to quit.106



Several documents have suggested general principles on which Indigenous-specific social marketing strategies could be based.20,21,72,80 These have been summarised in the document Developmental Research to inform the National Action to Reduce Smoking Rates Social Marketing Campaign.21 This research project involved conducting interviews and focus group discussions with over 220 Indigenous people and 30 Aboriginal and non-Aboriginal health professionals from communities across Australia. The study investigated issues around the development of social marketing campaigns to address smoking in Indigenous communities. A series of recommendations around strategic directions in media campaigns, communications strategies and message delivery have been proposed based on the findings from this research and a review of existing literature.21

This study proposes that communications strategies in Indigenous anti-tobacco social marketing should place a strong focus on the benefits for family and kin of quitting, including emphasising the impact of the financial cost of smoking on the family, and the adverse effects of smoking on health and fitness on the individual smoker and their family. Delivery of these messages should use Indigenous faces, voices and imagery and frame the messages in a positive and inspirational way. In addition, messages should be delivered using clear, jargon-free and regionally appropriate language, utilise local Indigenous people, use a narrative approach, and feature true stories and real people. Messages that are framed in terms of immediacy of impact (rather than a future focus) are likely to have a greater impact.21 These suggested approaches have been (or are being) used in the development of the national social marketing campaign, Break the Chain,119 and these messages are also reflected in a number of local campaigns117,120 (see also footnote).

Revival, nurturing and continuation of Indigenous cultural heritage are strong motivating factors for some individuals and communities, and have also been put forward as suitable approaches in Indigenous social marketing campaigns. Highlighting the connection between not smoking, good health and survival may therefore be a salient message for some Aboriginal and Torres Strait Islander smokers.72 Although, as discussed elsewhere in this chapter, Indigenous culture and tobacco use have long been connected, the smoking of manufactured cigarettes is an introduced activity. One project has reported that younger smokers in particular showed an interest in this message: ‘it’s not part of our culture—give it back’.72 Several organisations in Australia have also used culture and the threat of smoking to culture as a theme in their social marketing. For example, the Kimberley Aboriginal Medical Services Council has developed posters using the slogans: ‘Stop the Smoke! You and country are one. You poison yourself. You poison your country too!’; ‘Look, listen and learn. Tobacco smoking kills’; and ‘Traditional smoking heals. Tobacco smoking kills’.116

Practitioners and researchers in Indigenous tobacco action are clear that social marketing is an important component of a comprehensive tobacco action program, and that a social marketing approach should use a combination of mainstream and Indigenous-specific content and messages, at both national and regional/local levels.21

8.10.11.1

Social media and mobile phonesThe potential for the use of digital technologies in the production and distribution of tobacco cessation and prevention messages in Indigenous communities is significant; videos and messages can be produced relatively inexpensively and distributed quickly and widely via social media websites and through mobile phone technology. The use and uptake of digital technologies by Indigenous youth is increasing rapidly, including in remote communities.121 Several projects and organisations are beginning to use social media websites to produce and spread these videos.i

While mobile phone messaging to disseminate smoking cessation messages and support has not been widely used with Aboriginal peoples and Torres Strait Islanders, it has been found to be acceptable to Māori people, including young people.122,123 A study involving Māori and non-Māori found that using mobile phones to communicate

i For examples of videos, websites and Facebook pages, see: http://www.skinnyfishmusic.com.au/site/programs/102-no-smoking-videos/402-miwatj-health-no-smoking-videos- ; http://www.facebook.com/pages/Tharawal-Aboriginal-Corporation-Airds/104220079641154?ref=ts ; http://www.facebook.com/pages/Kick-the-Habit/303274051400 ; http://www.youtube.com/user/nosmokestv?feature=mhee ; and http://www.nosmokes.com.au/

http://www.skinnyfishmusic.com.au/site/programs/102-no-smoking-videos/402-miwatj-health-no-smoking-videos-

http://www.facebook.com/pages/Tharawal-Aboriginal-Corporation-Airds/104220079641154?ref=ts

http://www.facebook.com/pages/Kick-the-Habit/303274051400

http://www.youtube.com/user/nosmokestv?feature=mhee

http://www.youtube.com/user/nosmokestv?feature=mhee

http://www.nosmokes.com.au/



smoking cessation messages resulted in an increase in short-term self-reported quit rates, and was equally successful with Māori as with non-Māori.123

8.10.12

Secondhand smokeHigh smoking rates make exposure to secondhand smoke a health issue for many Aboriginal peoples and Torres Straits Islanders, particularly infants and children (see Section 8.7.4). Secondhand smoke has been documented as an issue of concern to Indigenous smokers, particularly in relation to its effect on children.72 Several studies have described how smokers have implemented smokefree practices to protect the health of children and/or to support their own quitting attempts.12,124 The impact of secondhand smoke on the health of children and family has been documented as a motivator for smoking behaviour change, whether quitting, reducing the number of cigarettes smoked or smoking away from non-smokers.15,19,58,59 Several initiatives have been developed specifically for Indigenous communities around secondhand smoke, but these have not been evaluated.48,115 A trial is underway in Darwin and Greater Darwin (Northern Territory) and in a metropolitan setting in New Zealand to assess the impact of a family-centred home-visit-based initiative that specifically addresses environmental tobacco smoke on the exposure of Indigenous babies and children to smoking.125

Smokefree workplaces have been found in mainstream studies to reduce exposure to secondhand smoke and to reduce cigarette consumption, increase the rate of quit attempts, and reduce the rates of relapse in smokers who are attempting to quit.126,127 Smokefree policies in Indigenous health services are seen to support other tobacco action activities by contributing to the denormalisation of tobacco use within Indigenous communities, supporting Aboriginal health workers and patients who smoke to quit, and reducing exposure to secondhand smoke. Many Aboriginal community controlled health organisations around the country have developed and implemented smokefree workplace policies (or are in the process of doing so). There has been no evaluation specifically of the impact of these smokefree policies on quit rates (as they are generally one of several components of comprehensive tobacco action programs), but several services have documented the processes of developing and implementing these policies.40,45 128 Anecdotally, the challenges in this area are largely around implementing the smokefree policies; Aboriginal health workers have reported difficulties in requesting compliance from community members, particularly when the community has not been engaged in the process.73

8.10.13

Specific sub-populations

8.10.13.1

Aboriginal health workersA number of multi-component projects have been developed specifically to support Aboriginal health workers to quit smoking. These projects generally include a range of activities, such as providing free nicotine replacement therapy, support groups, intensive follow-up, support for families of Aboriginal health workers to quit alongside them, incentives for staff to quit, and smokefree workplace policies.45,128 While these projects appear to be having some success (both in terms of participation and quit rates), and data collection for evaluation is underway, these findings are not yet published. A research project in South Australia is investigating the social context of smoking behaviour of Aboriginal health workers with the aim of developing, implementing and evaluating an appropriate intervention to increase smoking quit rates among Aboriginal health workers in South Australia.129



8.10.13.2

Youth and childrenReviews of mainstream studies have found that there is limited evidence for the effectiveness of school-based programs for smoking prevention among youth when the programs are based on information giving or developing general social competence,130 but that coordinated, widespread, multi-component community interventions are effective.131 Mass media campaigns may also be effective for young people when well researched and appropriately developed and delivered.132

Smoking prevention programs aimed at children are recognised as a priority area for action by many Indigenous people.15,19,72 Respondents to the National Aboriginal and Torres Strait Islander Tobacco Control Project Survey felt that schools-based programs must begin in the early primary years, and should be reinforced at every year level, at every opportunity. Appropriate and appealing resources using visual, interactive and memorable elements (such as jingles and songs) were thought to be helpful. It was also considered important to provide adequate recreational facilities and organised activities to support children through the hours when they are not at school, when key factors contributing to uptake—such as peer group pressure, concerns for personal image and boredom—may be at their height.15

However, as suggested by the evidence from the mainstream context, school-based programs alone are clearly not sufficient to address smoking uptake by young people. Even were school-based programs shown to be effective, in communities where school attendance is sporadic, other means of conveying messages to children need to be found.133 The importance of family influence on smoking behaviours highlights the potential of family- and community-based interventions, which target both adults and children to impact the rates of uptake among youth.19,134 Reducing the social acceptability of smoking in Indigenous communities, and reducing smoking among significant adults who are likely to influence young people to take up smoking, should arguably receive a greater emphasis in these programs. Indigenous participants in an evaluation of the National Tobacco Campaign felt that the emphasis of tobacco-control programs should be on older smokers, as they felt that smoking was highest in this group, that many were suffering from smoking-related illnesses, and that they would be most likely to in turn influence other community members, including young people, to quit.20

While there have been several tobacco action initiatives that target Indigenous young people, none have been evaluated for their impact on smoking uptake. Some of these programs have been school based,133,135 while others have been community based,136,137 or part of multi-component programs.37,42,52,55,138,139 An analysis of Victorian data from the Australian Secondary Students’ Alcohol and Drug Survey shows an association between intensive anti-tobacco campaigns and reduced prevalence of smoking among Indigenous (and non-Indigenous) school students.140

8.10.13.3

Pregnant womenA review of mainstream studies found that smoking interventions during pregnancy result in reduced smoking during late pregnancy, and improved birthweight.141 The majority of published studies of smoking in Indigenous pregnant women are descriptive studies (see sections 8.3.3, 8.6 and 8.7.4). A number of projects and intervention research projects are underway or in the process of being published. There are several projects that are focused specifically on providing training and resources: the Indigenous Women’s Project through the Asthma Foundation Western Australia;115 the Smoke-free Pregnancy Project—Aboriginal Women and their Families through Quit South Australia;142 and the For Me & Bub SmokeCheck Pregnancy Project in Queensland.143 A randomised controlled trial investigating the effectiveness of a high-intensity intervention with pregnant women at three Indigenous health services in Queensland and Western Australia is completed (at September 2011), but the results are not yet available. A pilot study associated with the project found no difference in smoking cessation rates between the control and intervention groups; however, the rate of smoking cessation achieved overall was 11%.144

A multi-component program, Goreen Narrkwarren Ngrn-toura (Healthy Family Air), is being developed and evaluated in Victoria. This project involves a three-pronged approach of training health staff, improving



organisational capacity and integrated support within health services, and community development.7,43 A literature review produced for this project suggests the integration of services for pregnant women into existing clinical practice, incorporating tobacco action activities into routine antenatal care practices. It also suggests a multi-component program, including tobacco action activities targeting the family and community such that a more supportive environment for quitting is created for the pregnant woman.7 The project has been broadened to include the whole community because of the many influences that the family and community have on pregnant women.43

A further component of programs with pregnant Indigenous women that is yet to be evaluated is the use of incentives. While reviews of studies have shown that the use of incentives (such as payments, rewards and competitions) may have an initial impact on quitting, they do not make a sustained impact on smoking rates.145 Several programs in other countries have shown success with using incentives to assist pregnant women to quit smoking.146,147 A review of smoking interventions with pregnant women found that the most successful intervention appeared to be the use of incentives.141 Another review has suggested that the use of incentives is likely to be improved by the value, the immediacy to the positive behaviour, the periodic (as opposed to one-off) delivery of the reward, rewarding support from the individual’s social network, and being part of a broader program that also builds skills and confidence.148 A program to help pregnant Aboriginal women in rural New South Wales to quit smoking has been developed as a result of three years previous research, and includes an incentives-based program offering rewards in gradually increasing amounts until six months postpartum. These rewards are being offered within a comprehensive program that also includes counselling, provision of specifically designed resources, free nicotine replacement therapy for the women and those in their households, quit support groups and household resources.44

8.10.13.4

PrisonersHigh rates of smoking by Indigenous prisoners (see Section 8.3.5) present an opportunity to provide cessation programs, although there are significant challenges to providing tobacco-control activities within prisons.149 Tobacco is a commodity that plays an important social role within prisons, and there is considerable debate over the practical and moral issues around the management of smoking within prisons (including making prisons, or even parts of prisons, smokefree).150 To be successful in this context, smoking cessation programs should take into account the unique stresses of the prison environment.151 Programs should also be ongoing to accommodate the constantly changing prison population, and the changes in the readiness to quit of individual prisoners.150 Smoking cessation programs do exist within some prisons,149 with some specifically targeting Indigenous prisoners,6,152 but there has been little evaluation of these programs for their impact on smoking cessation. One study that evaluated a program in a New South Wales prison—where participants (n=30, with 50% Aboriginal) were offered a combination of bupropion, nicotine replacement therapy, brief cognitive behavioural therapy and self-help resources—found a quit rate of 26% at six months, with the rest of the participants reporting that they smoked less tobacco per week.153 The greatest barrier to implementing smoking cessation programs within prisons is the lack of resourcing; funding available through the Closing the Gap initiatives have not been directed towards prisons.150

8.10.14

Broader legislationState/territory and Commonwealth legislation that controls advertising and packaging, taxation and pricing, smokefree public areas and sales has been found to be successful in the general Australian community in reducing consumption and/or access to tobacco products(see Chapter 13). However, the impact of such legislation on smoking rates among Indigenous people has not been evaluated. Increasing taxes on tobacco has been shown to reduce consumption in the general Australian community, and has been shown to result in a greater decline in consumption among low-income groups than among middle- and high-income groups.154 The National Aboriginal and Torres Strait Islander Tobacco Control Project cautioned against price increases because of concern about causing financial stress that could in turn lead to greater levels of smoking.15 In a 2007 qualitative study involving community members (25) and health staff (19) in remote Northern Territory communities, perceptions of the



impact of price increases were conflicting. While participants suggested that higher prices were not a disincentive to smoking, they also talked about changing their smoking behaviour and accessing a smaller number of cigarettes when money was scarce.12 In this same study, participants described the difficulties in remote communities of enforcing existing legislation around smokefree public places, and that the lack of other Northern Territory legislation was undermining their tobacco-control efforts. Participants also reported good recall about the picture health warnings on tobacco products, but some reported disregarding these and employing strategies to avoid seeing the images.12



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151. Richmond R, Butler T, Wilhelm K, Wodak A, Cunningham M and Anderson I. Tobacco in prisons: a focus group study. Tobacco Control 2009:tc.2008.026393. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/tc.2008.026393v1

152. Justice Health Quit Smoking Project (CEITC Project Register). Melbourne, Australia: Centre for Excellence in Indigenous Tobacco Control, The University of Melbourne, viewed 2 September 2011. Available from: www.ceitc.org.au/indigenous-projects-register

153. Richmond RL, Butler T, Belcher JM, Wodak A, Wilhelm KA and Baxter E. Promoting smoking cessation among prisoners: feasibility of a multi-component intervention. Australian and New Zealand Journal of Public Health 2006;30(5):474–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17073232

154. Siahpush M, Wakefield M, Spittal MJ, Durkin SJ and Scollo MM. Taxation Reduces Social Disparities in Adult Smoking Prevalence. American Journal of Preventive Medicine 2009;36(4):285–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19201146



8.11

The relationship between tobacco and other drug use in Aboriginal and Torres Strait Islander communitiesAboriginal peoples and Torres Strait Islanders have a higher prevalence of experimentation and usage of most other drugs compared with the non-Indigenous population.1 The health and social damage caused by alcohol and other drug misuse in some communities is immediate and highly visible, and the reason why tobacco use may be regarded as a lesser health issue and of lower urgency than other drug issues—see also Section 8.9.4.2,3 The purpose of this section is to place tobacco in the context of other drug use.

Table 8.11.1 shows the prevalence of smoking, alcohol and other drug use in the Indigenous population aged 15 and over as collected through the National Aboriginal and Torres Strait Islander Social Survey of 2008 and reported in The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2010, and Substance Use among Aboriginal and Torres Strait Islander People.1,4 Two measures of risk from drinking alcohol were reported:

< chronic or long-term risk was based on amounts of alcohol consumed on a usual day and the frequency of consumption in the previous 12 months

< acute risk (or binge drinking) was based on the largest quantity of alcohol consumed in a single day during the fortnight prior to interview.

Seventeen per cent of Aboriginal peoples and Torres Strait Islanders aged 15 years and over reported drinking alcohol at chronic risky/high-risk levels, while 37% reported risky/high-risk levels of binge drinking in the fortnight prior to interview.4 Twenty per cent of Aboriginal peoples and Torres Strait Islanders reported using illicit substances in the 12 months before interview, with marijuana (16%) and amphetamines (10%) the most common type of illicit drugs used in the past 12 months.4 The 2008 National Aboriginal and Torres Strait Islander Social Survey also found that, like non-Indigenous smokers, Indigenous daily smokers were more likely than those who had never smoked to have drunk at chronic risky/high-risk levels and to have engaged in binge drinking (acute risky/high-risk levels) in the past two weeks. Daily smokers were also more likely to have used illicit substances in the previous 12 months.4

Unfortunately, conceptual and methodological differences means that the National Aboriginal and Torres Strait Islander Social Survey data are not directly comparable to data from the 2004–05 National Aboriginal and Torres Strait Islander Health Survey5 or the 2004–05 National Health Survey,6 although for alcohol use these two data sets can be compared to each otheri. Comparisons with non-Indigenous illicit substance use cannot be made as the relevant survey (the National Drug Strategy Household Survey) used different questions, reported on different

i In addition, these surveys use different age groupings with the NATSISS collecting data from age 15 years and above, while the NATSIHS and 2004–05 National Health Survey collect data from age 18 years and above.

Table 8.11.1 Prevalence of smoking, alcohol consumption and other substance use among Indigenous persons aged 15 and over, Australia, 2008

%SmokingCurrent smokers 47AlcoholChronic risky/high-risk levels of alcohol consumption* 17Acute risky/high-risk alcohol consumption (binge drinking)† 37Other illicit or controlled substances used in the last 12 months

Painkillers or analgesics (used for non-medicinal purposes)

Ever used 7

Used in last 12 months 4

Amphetamines or speedEver used 10


Marijuana, hashish or cannabisEver used 33


Ecstasy or designer drugsEver used 7


Had not used illicit substancesNever used 61

Not in last 12 months 80

* Risk levels are based on the person’s self-reported usual daily consumption of alcohol (in mL) and the frequency of consumption in the previous 12 months, and are defined in the 2001 National Health and Medical Research Council Australian Drinking Guidelines

† Based on the largest quantity of alcohol (mL) consumed in a single day during the fortnight prior to interview

Source: ABS and AIHW 20104



groupings, and was conducted at different times from the 2004–05 national Aboriginal and Torres Strait Islander social and health surveys.1 Although the 2007 National Drug Strategy Household Survey found that Indigenous people were almost twice as likely as other Australians to be recent users of illicit substances, the small sample size of Indigenous people in the survey means that this finding should be interpreted with caution (see footnote i in Section 8.3).7

The following sub-sections discuss alcohol and marijuana use in greater detail as these substances are, after tobacco, the most widely used among Aboriginal peoples and Torres Strait Islanders. In addition, tobacco smoking often occurs alongside drinking alcohol and/or smoking marijuana. Data is drawn from the 2008 National Aboriginal and Torres Strait Islander Social Survey, and where comparisons are made with the non-Indigenous population, from the 2004–05 National Aboriginal and Torres Strait Islander Health Survey and 2004–05 National Health Survey.

8.11.1

AlcoholA smaller proportion of Aboriginal peoples and Torres Strait Islanders consume alcohol regularly than the overall Australian population, but of those who do drink alcohol, a higher proportion consumes it at risky or high-risk levels.1 When comparing age-standardised data from the 2004–05 National Aboriginal and Torres Strait Islander Health Survey and 2004–05 National Health Survey, nearly twice as many Indigenous people did not consume alcohol in the 12 months prior to the survey than non-Indigenous people (29% compared with 15%). Non-Indigenous people were also 1.5 times more likely to have drunk alcohol in the week before the survey. There was no significant difference between the proportions of Indigenous and non-Indigenous people who drank at long-term risky or high-risk levels (15% and 14%). However, Indigenous people were 1.2 times more likely to have been binge drinking in the 12 months prior to the survey, and twice as likely to have been binge drinking at least once a week in the previous 12 months (17% compared to 8%).1

As noted earlier, the 2008 National Aboriginal and Torres Strait Islander Social Survey reports that 17% of Aboriginal peoples and Torres Strait Islanders aged 15 years and over have used alcohol at chronic risky/high-risk levels in the last 12 months. Proportions of chronic risky/high-risk drinking was higher among men than women (20% compared with 14%), and highest among those aged 35–44 years (22%). Rates of risky/high-risk drinking were similar for residents in remote and non-remote areas, but Indigenous people in remote areas were more likely than those in non-remote areas to have abstained from alcohol in the past 12 months (46% compared with 31%).4 Binge drinking (drinking at acute risky/high-risk levels in the two weeks prior to interview) was reported by 37% of Aboriginal peoples and Torres Strait Islanders aged 15 years and over, and was also more common among males than females (46% compared with 28%), and higher among those living in non-remote than remote areas (38% compared with 33%).4

Aboriginal peoples and Torres Strait Islanders who reported risky/high-risk binge drinking were more likely to be current daily smokers compared to those who drank at low risk levels (59% compared to 33%). Similarly, those who drank at chronic risky/high-risk levels were also more likely to be current daily smokers than those drinking at low risk levels (63% compared with 46%).4 A higher prevalence of smoking, combined with greater incidence of risky drinking levels, leads to an increased risk of developing cancers of the oral cavity oesophagus and larynx8 (see Section 8.7.3.2).

Studies comparing alcohol use between Indigenous and non-Indigenous teenagers have shown various results. Data from the 2009 Victorian Adolescent Health and Wellbeing Survey (a school-based survey in years 7, 9 and 11) show that while similar levels of Aboriginal and non-Aboriginal young people had ever drunk alcohol (71.3% and 61.9% respectively), Aboriginal young people were more likely to have had five or more alcoholic drinks in a row in the last two weeks (37.8% compared with 18.3%).9 Similarly, a 1996 survey of New South Wales Indigenous students aged 12–17 found that they were about as likely as non-Indigenous students to report weekly drinking of alcohol, but were twice as likely to report hazardous drinking.10 Other studies among youth, however, show that Indigenous young people are either less likely or about as likely to have experimented with alcohol or to have drunk frequently/to excess as non-Indigenous young people.11–13 The findings of two of these surveys of Indigenous young people have been compared to non-Indigenous surveys that are not directly comparable (due to timing



of their administration, methodology or the questions asked), although they do give a broad indication.11,13 The Western Australian Aboriginal Child Health Survey reported that those young people who drank alcohol but not to excess were four times more likely to smoke regularly than young people who did not drink at all, and young people who drank to excess were 4.5 times more likely to smoke than those who did not drink.13

8.11.2

Cannabis (marijuana, hashish, ‘ganja’ or ‘yarndi’)As reported above, the 2008 National Aboriginal and Torres Strait Islander Social Survey shows that one-third of Aboriginal peoples and Torres Strait Islanders had ever tried marijuana, and 16% had used it in the last 12 months. Of current daily smokers aged 15 years and over, 26% reported using marijuana in the last 12 months, compared with 9% of ex-smokers and 5% of those who had never smoked.4 The National Aboriginal and Torres Strait Islander Health Survey 2004‒05 found that 46% of Indigenous smokers in non-remote regions aged between 18 and 34 had used marijuana, hashish or cannabis resin in the past year, compared with 16% of Indigenous non-smokers.14 As stated above, there is no data available that enables comparison of marijuana use between Indigenous and non-Indigenous populations.

Other research suggests that level of usage may be higher still in some communities. A 2000–01 study from eastern Arnhem Land (in the ‘Top End’ of the Northern Territory) found that 70% of Indigenous males and 59% of females were current users of cannabis.15 Of those who were current users, 61% used it weekly or more often, and few who had ever used cannabis had quit (7%). Cannabis use was strongly associated with tobacco use. Current tobacco smokers were about three times as likely to use cannabis as were non-smokers, and a third of those who had ever used both cannabis and tobacco began using the substances at or near the same time. Most current cannabis users (84%) were also using tobacco; the favoured method of cannabis use was to combine it with tobacco, the mixture commonly being smoked via a bucket bong, allowing a number of users to share. Some communities may be spending between 31% and 60% of their weekly income on cannabis; combining it with less expensive tobacco ekes out the supply. This study concluded that cannabis use helped reinforce continued tobacco use, that widespread adoption of using cannabis in combination with tobacco could have serious health consequences, and that joint dependence on these substances provided a major challenge to communities and to those working in public health.15

Studies of illicit drug use among Indigenous teenagers show varied results. The Victorian Adolescent Health and Wellbeing Survey (2009) found no significant difference between the proportions of Aboriginal and non-Aboriginal young people who had ever used illicit drugs.9 Likewise, a comparison of data from the 2000–02 Western Australian Aboriginal Child Health Survey and the 2002 Australian Secondary Students’ Alcohol and Drug Survey found that similar proportions of Indigenous and non-Indigenous young people in Western Australia had used marijuana at some time (30% and 31% respectively), and in the previous week (11.9% and 9% respectively).13,16 On the other hand, a 1996 survey of school students aged 12–17 in NSW found that Aboriginal students were 1.6 times more likely to have ever tried cannabis than non-Aboriginal students.10 The Western Australian Aboriginal Child Health Survey found that young people who used marijuana weekly or more often were 11 times more likely to smoke than those who did not use marijuana.13

The National Aboriginal and Torres Strait Islander Tobacco Control Project also found that cannabis was widely used among various Aboriginal and Torres Strait Islander communities, and that its use was closely connected with tobacco use. It was commonly reported that cannabis was mixed with tobacco, and that even if the primary aim was to use cannabis, tobacco addiction would result.2 While some communities felt that the relationship between tobacco and cannabis was so interconnected that one could not properly be addressed without the other, other communities expressed the view that the importance of cannabis use and its illicit status meant that it was best dealt with as a separate issue. These matters are clearly for individual communities to decide.2

There may also be widespread misconceptions about the health effects of cannabis use. The National Aboriginal and Torres Strait Islander Tobacco Control Project study found that many respondents perceived cannabis as more ‘natural’ and hence less harmful than manufactured tobacco products.2 The health consequences of cannabis use are discussed in Chapter 3, Section 3.32.2.



References1. Australian Institute of Health and Welfare. Substance Use among Aboriginal and Torres Strait Islander people. Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/

publications/ihw/40/11503.pdf





6. Trewin D. 4364.0 National Health Survey: summary of results, 2004–05. Canberra: Australian Bureau of Statistics, 2006. Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4364.02004-05?OpenDocument



9. Department of Education and Early Childhood Development. The state of Victoria’s children 2009: Aboriginal children and young people in Victoria. Melbourne, Australia: Department of Education and Early Childhood Development, 2010. Available from: http://www.education.vic.gov.au/about/directions/children/vcams/vcamsreports.htm

10. Forero R, Bauman A, Chen J and Flaherty B. Substance use and socio-demographic factors among Aboriginal and Torres Strait Islander school students in New South Wales. Australian and New Zealand Journal of Public Health 1999;23:295-300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10388175

11. Gray D, Morfitt B, Ryan K and Williams S. The use of alcohol and other drugs by young Aboriginal people in Albany, Western Australia. Australian and New Zealand Journal of Public Health 1997;221:71-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9141733

12. Dunne M, Yeo M, Keane J and Elkins D. Substance use by Indigenous and non-Indigenous primary school students. Australian and New Zealand Journal of Public Health 2000;24:546-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11109696

13. Zubrick S, Lawrence D, Silburn S, Blair E, Milroy H, Wilkes T, et al. The Western Australian Aboriginal Child Health Survey: the health of Aboriginal children and young people. Perth, Australia: Telethon Institute for Child Health Research, 2004, [viewed September 2007]. Available from: http://www.ichr.uwa.edu.au/waachs


15. Clough R. Associations between tobacco and cannabis use in remote indigenous populations in Northern Australia. Addiction 2005;100(3):345-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15733248

16. Zubrick S, Silburn S, Garton A, Burton P, Dalby R, Carlton J, et al. Western Australian Child Health Survey: developing health and well-being in the nineties. Perth, Australia: Australian Bureau of Statistics and the Institute for Child Health Research, 1995. Available from: http://www.ichr.uwa.edu.au/files/user20/ichr%204303_5.pdf






tobccamp_g.pdf




47150_2004-05.pdf



http://www.surgeongeneral.gov/library/smokingconsequences

http://www.education.vic.gov.au/about/directions/children/vcams/vcamsreports.htm




http://www.ichr.uwa.edu.au/waachs




http://www.ichr.uwa.edu.au/files/user20/ichr

204303_5.pdf



8.12

The tobacco industry and Indigenous communitiesGiven the strong consumer base they provide, it is not surprising that Aboriginal peoples and Torres Strait Islanders have been targeted by tobacco industry marketing practices, along with other vulnerable and disadvantaged populations. A former tobacco model recounted during a court case against a tobacco company what he was told by a tobacco company executive: ‘We don’t smoke the shit. We just sell it. We reserve the right to smoke for the young, the poor, the black and the stupid’ (p 26).1

Direct tobacco advertising in Australia now being a thing of the past, tobacco companies have found other ways to promote themselves among Indigenous communities. One company supported an Indigenous football team by donating a percentage of every dollar spent on a particular brand towards buying football guernseys for the team.2 Yet more questionable was the provision of funding in 2001 by Philip Morris Australia to the Victorian Aboriginal Education Association Incorporated for the development of materials about substance use.3 Sponsorships of this nature could provide the impression that tobacco itself is not a cause for concern compared with other drug misuse, and might also influence the willingness of communities to take up and support tobacco-control initiatives.

There is anecdotal evidence that the close connection for many rural Indigenous people with cattle farming has made the Philip Morris brand Marlboro, with its iconic symbol of the smoking cowboy, a popular brand choice.2,4 Winfield, manufactured by Rothmans, is also strongly associated with the laconic working man through its launch using popular actor Paul Hogan in the 1970s. Winfield is also a leading brand used among Indigenous people;2 in the APYi lands in Central Australia, 90% of the market share is held by Winfield (compared to 31.7% in the national market).5

Interestingly, Rothmans used the image of an Australian Indigenous man playing the didgeridoo in an advertisement for its Winfield brand, launched in Germany in 1998.6 In 2005 Philip Morris launched a brand in Israel called Maori Mix, which incorporated ‘quasi-Māori’ emblems and a map of New Zealand on the packaging.7 The exploitation of Australian and New Zealander Indigenous peoples, among whom tobacco is a leading cause of death and disease, attracted immediate criticism.6,7 The Māori people received an apology.7

In New Zealand, resistance to exploitation by the tobacco industry is part of the messages delivered by Māori anti-tobacco advocates. Underpinning a series of campaigns—entitled ‘Māori Killers’, ‘Endangered Species’ and ‘Māori Murder’—is the idea that the tobacco industry profits from Māori tobacco-related illness and death, and tobacco is a ‘barrier to Māoridom fulfilling its full potential’.8 This approach has not been widely used by Aboriginal peoples and Torres Strait Islanders in Australia.

i Anangu Pitjantjatjara Yankunytjatjara



References1. Deposition of David Goerlitz for ‘The State of Oklahoma et al, Plaintiffs vs. RJ Reynolds et al, Defendents. GOERLITZD110998. Cleaveland, Oklahoma: District Court for Cleveland County,

1998. Available from: http://legacy.library.ucsf.edu/tid/ufr07a00/pdf


3. Metherell M. Smoke giant offers lesson for schools. Sydney Morning Herald, 2002:21 Sep. Available from: http://www.smh.com.au/articles/2002/09/20/1032054962835.html

4. Roche A and Ober C. Rethinking smoking among Aboriginal Australians: the harm minimisation-abstinence conundrum. Health Promotion Journal of Australia 1997;7(2):128-33. Available from: http://search.informit.com.au/documentSummary;dn=460464653536793;res=IELHEA

5. Butler R, Chapman S, Thomas DP and Torzillo P. Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities. Australian and New Zealand Journal of Public Health 2010;34(suppl. 1):S71–75. Available from: http://dx.doi.org/10.1111/j.1753-6405.2010.00557.x

6. Chapman S. The ugly Australian from Rothmans, in Germany. Tobacco Control 1999;8:362. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1759737/pdf/v008p00362a.pdf

7. Maori Mix cigarettes in Israel ignites row. New Zealand Herald, (Auckland) 2005:13 Dec. Available from: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10359703

8. Te Reo Mārama. Kaupapa Tupeka Kore – Tobacco Free. Homepage. Wellington: Te Reo Mārama, 2011, viewed 1 July 2011. Available from: http://www.tereomarama.co.nz/Site/default.aspx

http://legacy.library.ucsf.edu/tid/ufr07a00/pdf


http://www.smh.com.au/articles/2002/09/20/1032054962835.html


http://dx.doi.org/10.1111/j.1753-6405.2010.00557

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1759737/pdf/v008p00362a.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1759737/pdf/v008p00362a.pdf

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10359703

http://www.tereomarama.co.nz/Site/default.aspx



8.13

Policies for advancing tobacco control programs among Aboriginal peoples and Torres Strait IslandersOver the past decade the amount of information about the use of tobacco and its impact on the health and wellbeing of Aboriginal and Torres Strait Islander populations has increased dramatically. The preceding sections have drawn on a broad range of research reports, some of which have made specific recommendations about appropriate policy directions for effective tobacco interventions in the Indigenous population.1–10. These reports and the many community members, health professionals, researchers and policy-makers working in the area of Indigenous tobacco control have advocated for a coordinated policy framework and action in this area supported by adequate and sustained funding. Commonwealth, state and territory governments have responded to these calls and to the emerging evidence around the harms of smoking in Indigenous communities. In the context of a public health policy environment with an increased emphasis on preventive health and a commitment to reducing Indigenous disadvantage, Australian governments at all levels have undertaken to take a coordinated approach to Indigenous smoking and have committed significant funding to support it. The Tackling Indigenous Smoking Initiative will be described further below, but first it is important to have a sense of the broader policy environment around Indigenous tobacco control, including the international and national policy contexts.

8.13.1

The Framework Convention on Tobacco ControlTobacco action in Aboriginal and Torres Strait Islander communities does not happen in isolation of Australia’s obligations on the international policy stage. As a signatory to the World Health Organization Framework Convention on Tobacco Control (FCTC), the Australian government is committed to taking legislative and regulatory actions that impact on tobacco sales, packaging, advertising, promotion and sponsorship.11 Furthermore, the FCTC specifically expresses that Parties to the Convention are ‘Deeply concerned about the high levels of smoking and other forms of tobacco consumption by indigenous peoples’ (p2).11 The Convention commits signatories to develop and support multisectoral measures and coordinated responses that take into consideration ‘the need to take measures to promote the participation of indigenous individuals and communities in the development, implementation and evaluation of tobacco control programmes that are socially and culturally appropriate to their needs and perspectives’ (p6).11

8.13.2

The National Drug Strategy 2010–15 and the Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–09Current national drug policy (including both licit and illicit substances) is embodied in the National Drug Strategy 2010–2015: A Framework for Action on Alcohol, Tobacco and Other Drugs.12 Since its inception in 1985, the National Drug Strategy has advocated a harm minimisation approach with the three pillars of demand reduction, supply reduction and harm reduction. A set of companion documents relating to Indigenous drug control has been prepared alongside the earlier 2003–09 National Drug Strategy, with their points summarised in the Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009.13 Six ‘key result’ areas have been identified:

< enhanced capacity of individuals, families and communities to address current and future issues in the use of alcohol, tobacco and other drugs, and promote their own health and wellbeing



< whole-of-government effort in collaboration with non-government organisations to implement, evaluate and improve comprehensive approaches to reduce drug-related harm

< substantially improved access to the appropriate range of health and wellbeing services that play a role in addressing alcohol, tobacco and other drugs issues

< a range of holistic approaches from prevention through to treatment and continuing care that is locally available and accessible

< workforce initiatives to enhance capacity of community-controlled and mainstream organisations to provide quality services

< increased ownership and sustainable partnerships of research, monitoring, evaluation and dissemination of information.

The Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009 has been evaluated,14 and a new Aboriginal and Torres Strait Islander Peoples Drug Strategy is to be developed.12

8.13.3

The National Tobacco Strategy and state/territory tobacco strategiesThe National Tobacco Strategy is produced by the Ministerial Council on Drug Strategy, which comprises federal, state and territory government ministers representing health and law enforcement, as well as the Federal Minister for Education.i In planning the strategy, the Ministerial Council on Drug Strategy consults widely with government and non-government agencies engaged in tobacco control in Australia.15

The first National Tobacco Strategy (1999 to 2002–03)16 recognised that concerted action was required to reduce smoking prevalence among Aboriginal and Torres Strait Islander communities. This led to the funding and launch in 2000 of the National Aboriginal and Torres Strait Islander Tobacco Control Project, a joint initiative between the National Aboriginal Community Controlled Health Organisationii and the Department of Health and Aged Care.3

The current National Tobacco Strategy (2004–2009)15 builds on its precursor (the National Tobacco Strategy 1999 to 2002–03),16 identifying Indigenous tobacco use as a priority area for action, and recommending the introduction of a range of tobacco-control policy measures to reduce the harm and inequality caused by tobacco in Australia. These include:15

< regulation of all current and emergent forms of promotion < regulation of supply—so that tobacco products are available only to adults and are not enticing to children and teenagers

< regulation of taxation—subject to further analysis for particular population groups < regulation of packaging—including package information < regulation of place of use (smokefree environments) < regulation of the product itself (ingredients; new product development) < promotion of ‘Quit’ and ‘Smokefree’ messages < provision of cessation services, including access to treatment for dependence < community support and education < addressing of social determinants of health < provision of programs appropriate to needs of disadvantaged groups < resourcing and training of workforce (e.g. health professionals) < ongoing research, evaluation, monitoring and surveillance.

i See the National Drug Strategy website at: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/councils-committees-lpii National Aboriginal Community Controlled Health Organisation is the peak national body representing Aboriginal community controlled health services. See: http://www.naccho.org.au/

http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/councils-committees-lp

http://www.naccho.org.au/



The National Tobacco Strategy also refers to the Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003‒2009,13 discussed above, and the National Strategic Framework for Aboriginal and Torres Strait Islander Health—Framework for Action by Governments.17 Additional documentation supporting the National Tobacco Strategy that relates specifically to smoking in Aboriginal peoples and Torres Strait Islanders is available from the National Drug Strategy website.i The National Tobacco Strategy 2004–09 has been evaluated and a new strategy is in the process of being developed and is expected to be implemented in 2011.18

Each state and territory has developed and implemented its own tobacco strategy or action plan,19–24 or has tobacco-related strategies embedded within alcohol, tobacco and other drug strategies/action plans (i.e. Queensland25 and the Australian Capital Territory26). All of these strategies recognise Aboriginal peoples and Torres Strait Islanders as a particular target group for tobacco action. The ACT has also produced the Aboriginal and Torres Strait Islander Tobacco Control Strategy, 2010/11–2013/1427 and several states have developed advisory mechanisms for the development and implementation of tobacco strategies for Indigenous peoples.

8.13.4

National Preventative Health StrategyThe national Preventative Health Taskforce was established in April 2008 to develop a National Preventative Health Strategy focusing on three priority areas for action: obesity, alcohol and tobacco. In June 2009, the Taskforce released Australia: The Healthiest Country by 2020—National Preventative Health Strategy—The Roadmap for Action.28 A key action area identified in this document is to: ‘Work in partnership with Indigenous groups to boost efforts to reduce smoking and exposure to passive smoking among Indigenous Australians’. Six actions specifically related to this were recommended (p190–2):28

< establish multi-component community-based tobacco-control projects that are locally developed and delivered < enhance social marketing campaigns for Indigenous smokers, ensuring a ‘twin track’ approach of using existing effective mainstream campaigns complemented by Indigenous specific campaign elements

< provide training to Aboriginal and Torres Strait Islander health workers to improve skills in the provision of smoking cessation advice

< improve training in the provision of smoking cessation advice of other health professionals working in Aboriginal and Torres Strait Islander health services

< place specialist tobacco-control workers in Indigenous community health organisations to build capacity at the local health service level to develop and deliver tobacco-control activities

< provide incentives to encourage non-government organisations to employ Indigenous workers.

In addition, a number of recommendations were made specifically around improving data collection on tobacco use and behaviours among Indigenous people (p198):28

< increase sample sizes of the National Aboriginal and Torres Strait Islander health and social surveys to provide reliable indications of changes over time in each state and in the Northern Territory. This should be done in preference to trying to include sufficient Indigenous people in annual state population surveys

< use state population surveys to over-sample each year within two or three state health department regions with a high proportion of Indigenous residents, so that reliable estimates of prevalence at a regional level become available on a three-yearly basis

< analyse percentage changes in the prevalence of Indigenous smoking compared with percentage changes in previous periods, and compared with absolute and percentage changes in the non-Indigenous population

< extend the Australian Secondary Students’ Alcohol and Drug Survey to more remote areas of Australia and to Indigenous schools to ensure the inclusion of greater numbers of Indigenous children. This would enable a reliable indication of changes over time in Indigenous smoking in each state and territory

i http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/indigenous-drug-strategy-lp

http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/indigenous-drug-strategy-lp



< establish a panel of Indigenous people who are currently smokers to enable the monitoring of intentions and attempts to quit, amounts smoked and the prevalence of smoking indoors and around others. The panel could also be used to monitor the impact of tobacco-control policies among Indigenous people.

All of these recommendations have been accepted by the Commonwealth Government,29 with some of these being specifically addressed in the Tackling Indigenous Smoking Initiative described below.

8.13.5

The Tackling Indigenous Smoking InitiativeIn 2008, the Council of Australian Governments committed to targets for closing the gap on Indigenous disadvantage in the areas of health, education and employment. These targets included closing the life expectancy gap within a generation, and halving the gap in mortality for Indigenous children under five within a decade. Recognising the contribution of smoking to the health gap, ‘Tackling Smoking’ became a key initiative of the Council of Australian Governments’ National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.30 Commonwealth, state and territory governments have committed a total of almost $200 million over four years (2009–13) to reduce the smoking rate and the tobacco-related burden of disease within Aboriginal and Torres Strait Islander communities—$100.6 million from the Commonwealth Government and $98.09 million from the states and territories. This is to be achieved through:30

< social marketing campaigns to reduce smoking-related harms < Indigenous-specific smoking cessation and support services < continued regulatory efforts to encourage reduction/cessation in smoking < strategies to improve delivery of smoking cessation services, including nicotine replacement therapy.

Each jurisdiction has developed implementation plans detailing the activities that will achieve the objectives of the agreement, including in the area of smoking.i

The Tackling Indigenous Smoking Initiative is part of the Indigenous Chronic Disease Package, a broader set of strategies to address chronic diseases and risk factors more generally.ii In the area of smoking, the following activities have been undertaken or are planned under the leadership of a National Coordinator for Tackling Indigenous Smoking:31,32

< a staged roll-out of tobacco action workers (TAW) and Regional Tobacco Coordinators (RTC) across 57 regions (to work as part of teams with the Healthy Lifestyle Workers who are being funded through another component of the Indigenous Chronic Disease Package)

< training to support these positions (TAWs and RTCs) to deliver smoking cessation programs and supports in Indigenous communities

< training for the new and existing workforce in providing brief interventions in smoking < training, funding and supports to the TAWs and RTCs to develop and implement localised anti-smoking social marketing campaigns

< quit smoking role models and ambassadors at the local level to assist other smokers to quit < an enhancement of Quitline services to be more accessible to and appropriate for Aboriginal and Torres Strait Islander people

< social marketing campaigns for Indigenous people.

In addition to these initiatives, the Commonwealth Government has provided a further $14.5 million over the four-year period for 18 Indigenous tobacco-specific projects under the Indigenous Tobacco Control Initiative.32

i For details of the Implementation Plans under the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, see http://www.federalfinancialrelations.gov.au/content/national_partnership_agreements/indigenous.aspx

ii See http://www.health.gov.au/internet/ctg/publishing.nsf/Content/home-1

http://www.federalfinancialrelations.gov.au/content/national_partnership_agreements/indigenous.aspx

http://www.federalfinancialrelations.gov.au/content/national_partnership_agreements/indigenous.aspx

http://www.health.gov.au/internet/ctg/publishing.nsf/Content/home-1



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