2.15 Tobacco use
Why is it important?
Tobacco is one of the leading contributors to the burden of disease among Aboriginal and Torres Strait Islander peoples. Tobacco has been estimated to contribute 12% of the burden and 17% of the gap in health outcomes between Indigenous and non-Indigenous Australians (Vos et al. 2009).
The health impact of smoking is evident in the high rates of hospitalisation and deaths from tobacco-related conditions (e.g. chronic lung disease, cardiovascular disease and many forms of cancer) (Marley et al. 2014; IGCD 2012). In Australia, up to two-thirds of deaths in current smokers can be attributed to smoking (Banks et al. 2015). Current smokers are estimated to die an average of 10 years earlier than non-smokers. Among Indigenous Australians, smoking directly causes about one-third of the burden from cancers and cardiovascular disease and around 1 in 5 deaths (Vos et al. 2007). Maternal smoking during pregnancy increases the risk of poor outcomes for babies and children (see measure 2.21) and environmental tobacco smoke has adverse health effects for others who are in close proximity to a smoker (measure 2.03).
The National Tobacco Strategy 2012–2018 states that approximately 15,000 Australians die prematurely from tobacco-related diseases each year (Begg et al. 2007) and smoking imposes an estimated $31.5 billion financial burden on the community (Collins et al. 2008).
The latest data on smoking rates for the Indigenous population come from the 2012–13 Health Survey. In 2012–13, 44% of Indigenous Australians aged 15 years and over reported being a current smoker (42% smoked daily and 2% less than daily). After adjusting for differences in the age structure of the two populations, Indigenous Australians were 2.5 times as likely to smoke as non-Indigenous Australians.
Between 2002 and 2012–13, current smoking rates declined significantly by 7 percentage points for Indigenous Australians aged 15 years and over. The short-term trend from 2008 to 2012–13 was also significant (a 3 percentage point decline). Prior to 2002, rates had been quite static. Over the last decade, rates remained the same in very remote areas (at 56%) and declined elsewhere: by 10 percentage points in outer regional areas to 4 percentage points in remote areas. The smallest decline was in the NT (2 percentage points) and the largest in NSW (11 percentage points). The 15–17 year age group had the largest decline (33% to 19%). In the same period, there was a corresponding increase in the proportions of Indigenous Australians who were ex-smokers (from 15% to 20%) and who had never smoked (from 33% to 36%). For those who continue to smoke, there has been a decline in the average number of cigarettes smoked daily (from 15 in 2008 to 13 in 2012–13), although there is no safe level of smoking.
In 2012–13, Indigenous smoking rates were highest in the NT (54%) and lowest in the ACT (30%). Smoking rates for males (46%) were slightly higher than for females (42%). Rates were highest in the 25–34 year age group (54%) and lowest among those aged 15–17 years (19%) and 55 years and over (30%). This pattern was similar for non-Indigenous Australians. The Health Survey included a measure of blood cotinine levels; high levels indicating smoking or exposure to tobacco (e.g. second-hand smoke). Cotinine levels were high for 95% of reported current smokers aged 18 years and over, 14% of ex-smokers and 6% of those who had never smoked. Of the reported non-smokers in remote areas with high cotinine levels, 19% reported chewing tobacco daily.
Smoking status is associated with socio-economic factors and smoking rates are highest for Indigenous Australians in the most socially disadvantaged circumstances (Thomas et al. 2008). In 2012–13, Indigenous Australians aged 15 years and over were more likely to report being a non-smoker if they were employed, had completed Year 12, or had a high self-assessed health status. For Indigenous Australians aged 18 years and over, being a non-smoker was associated with being in the highest household income quintiles and having lower levels of psychological distress. Social, cultural and family factors also play important roles (Johnston et al. 2008; Hearn et al. 2011). Certain populations are more at risk. For example, in 2012, 92% of Indigenous prison entrants were current smokers (see measure 2.11) (AIHW 2013e). Those who smoked were also more likely to drink at risky levels (66% exceeded short-term guidelines) compared with those who did not smoke (44%).
Tobacco smoking is influenced by a range of factors, including normalisation of smoking in peer groups and families, positive attitudes towards smoking, and smoking as a coping mechanism (Robertson et al. 2013; Scollo et al. 2012). The influence of these factors varies across the different community settings and social environments in which Aboriginal and Torres Strait Islander peoples live (Johnston et al. 2008). Consequently, it is important that strategies to reduce Indigenous smoking rates acknowledge the social exchange that often occurs when smoking, the important role of family, and the high rates of stress experienced by Aboriginal people (Cosh et al. 2014; Hearn et al. 2011).
A Cochrane review of smoking cessation intervention studies in Indigenous populations internationally found limited rigorous evidence to evaluate which interventions would be effective in reducing tobacco use (Carson et al. 2012). There was some evidence supporting pharmacotherapies when combined with culturally tailored interventions and health professional support (Carson et al. 2014). A multifaceted approach addressing prevention and cessation from various sources simultaneously, and targeted to the population, appeared more likely to increase success together with evaluations to assess effectiveness.
Opportunities for prevention and intervention occur through both individual and community-based approaches and primary health care (NACCHO/RACGP 2012; Robertson et al. 2013). Lessons learnt from studies of interventions include the importance of local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety (Robertson et al. 2013; Hearn et al. 2011). Motivators and enablers to successfully quit smoking often involve significant life events and supportive relationships. Quitting smoking entails major changes in the person's life requiring resilience and empowerment, and encouragement and support from family, friends and health professionals (Bond et al. 2012).
Australian governments have worked closely with Indigenous Australians and health organisations over many years to deliver a range of approaches to address the high rates of tobacco smoking in the Indigenous population (see Figure 4). Smoking rates are starting to decline; however, they are still high, particularly in remote areas. Further sustained improvements will be needed to close the gap in health outcomes.
The National Tobacco Strategy 2012–2018 has nine priority areas for future action. One priority action is to build on existing programmes and partnerships to reduce smoking rates among Aboriginal and Torres Strait Islander peoples. The evidence-informed priority areas include demand reduction, supply reduction and harm reduction approaches (IGCD 2012).
Indigenous Australians are a major target audience of the National Tobacco Campaign. Specific advertising (Break the Chain) was placed in a range of Indigenous and mainstream media. The campaign encourages Indigenous smokers to cut down or quit and recent quitters to continue not to smoke and to encourage others to quit. The National Tobacco Campaign—More Targeted Approach (aimed at reducing smoking prevalence among high-risk and hard-to-reach groups) includes materials developed for Indigenous Australians. Materials featuring Indigenous women have been placed as part of the Quit for You, Quit for Two component, targeting pregnant women and their partners. Evaluation research found the campaign effectively promoted positive attitudes and intentions towards not smoking. Since 1 December 2012, all tobacco products have been required to be sold in plain packaging with updated and expanded graphic health warnings. Excise on tobacco and tobacco-related products was increased by 12.5 per cent on 1 December 2013 and 1 September 2014, with further 12.5 per cent increases to be implemented on 1 September 2015 and 2016.
The Tackling Indigenous Smoking programme provides a national platform for reducing Indigenous smoking rates. This programme includes promoting an understanding of the importance of smoke-free environments and compulsory smoke-free policies for funded organisations. The programme includes regional teams that work with communities to design and deliver locally tailored health promotion, social marketing and education campaigns and activities addressing smoking. The Government is committed to ensuring that programmes to address high rates of smoking are based on the most up-to-date evidence, and are delivered in a way that is appropriate, effective and efficient. An independent review of the Tackling Indigenous Smoking programme in 2014–15 will consider recent literature and research findings and make recommendations on how best to reduce Indigenous smoking rates.
Figure 2.15-1 shows the proportion of Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians aged 15 years and over reporting they are a current smoker in 2012–13. Data is presented for the following age groups: 15-17 years; 18-24 years; 25-34 years; 35-44 years; 45-54 years; and 55 years and over. Rates are higher among Indigenous than non-Indigenous Australians for each age group presented.
Source: 2012–13 AATSIHS (ABS 2014d)
Figure 2.15-2 shows the proportions of Aboriginal and Torres Strait Islander peoples aged 15 years and over, who are current smokers, ex-smokers, or who have never smoked, for the years 2002, 2008 and 2012–13. The graph shows that over time, the rate of current smokers has decreased, while the rates of ex-smokers and people who have never smoked have increased.
Source: 2012–13 AATSIHS (ABS 2014d)
Note: Comprehensive significance testing results are published in the Detailed Analyses
† Estimate has a relative standard error between 25% and 50% and should be used with caution.
Source: ABS and AIHW analysis of the 1994 NATSIS, 2002 and 2008 NATSISS and 2012–13 AATSIHS