8.10 Interventions targeting Aboriginal peoples and Torres Straits Islanders

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Although the health impact of tobacco use on Aboriginal peoples and Torres Strait Islanders is well-documented, program delivery to these populations has typically been marked by a lack of coordination and a paucity of resources. Critical evaluations of the various interventions that have been undertaken among Aboriginal and Torres Strait Islander communities are sparse and hence the question of what constitutes best practice for cessation programs among these communities remains largely unanswered.6, 115

The differences in history, cultural background and attitudes to health between these communities and other Australian populations makes it unlikely that interventions that have shown success elsewhere can be transplanted successfully to Australian Indigenous populations without at least some degree of modification, if at all. The differences between various Aboriginal and Torres Strait Islander communities also militate against the success of a 'one size fits all' program. Consultation, and community ownership and involvement are critical to the success of any interventions.

It is also essential to remember that while cultural and historical factors no doubt contribute to the high prevalence of smoking among Aboriginal and Torres Strait Islander communities, their comparative socioeconomic disadvantage is also a significant influence (see Sections 8.1, 8.2 and 8.3.1). 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. Further, other priority health and social issues for certain communities, such as alcohol and other drug use and domestic violence, need also to be addressed.57

A final matter worthy of comment is the fundamental conflict between the prevailing biomedical construct of health and disease, and the holistic view of health traditionally held by Aboriginal peoples and Torres Strait Islanders. This perspective—that 'health is life; life is health'; 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.16, 116

Several areas have been identified that are likely to be factors critical to the success of designing appropriate tobacco interventions for Aboriginal and Torres Strait Islander communities.

8.10.1 Need for a comprehensive approach

It is well-understood that addressing one part of tobacco control in isolation reduces the chances of success.111 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. 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.111

In view of limited evaluation of tobacco control programs in Aboriginal and Torres Strait Islander populations, Ivers50 has conducted a wide-ranging literature review in order to assess the likely success of various strategies in these communities. Those interventions which, appropriately designed and targeted, would be most likely to have a positive effect on smoking cessation include:

• Training for health workers in giving brief interventions
• Supporting quit attempts among health workers
• Routine provision of cessation advice—as brief interventions, and to target populations such as pregnant women and hospital inpatients
• Community interventions for young people, including school-based programs
• Quit courses and Quitlines
• Workplace tobacco programs
• Media campaigns
• Pharmacological aids
• Education about secondhand smoke in the home
• Health warnings, particularly with pictorial content
• Pamphlets and flipcharts
• Restriction of advertising and promotion
• Restriction of smoking in public places
• Reinforcement of laws regarding sales to minors
• Restricting or banning sales via vending machines

Ivers emphasises that until tested, the value of these various elements may only be inferred; but they could provide a useful starting point for the development of comprehensive and appropriate tobacco control programs for these populations.50

8.10.2 Increasing awareness of tobacco as a health priority

While it is generally well-understood by Aboriginal and Torres Strait Islander communities that tobacco use is harmful, it is not widely recognised as a health priority (see Section 8.9.3 above). It is probable that its general acceptance, coupled with the more immediately visible and destructive influences of alcohol and other drug use, have served to diminish perceptions of its importance as a health issue.6, 36, 112

The NATSITCP report points out, however, that a good understanding of the health dangers of smoking does not necessarily translate into quitting behaviour, suggesting that quit messages need to be based on issues of more salience to Indigenous communities.6 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. Tobacco interventions need to be part of a multilevel approach that recognises the broader social, economic and cultural environment of communities.57

8.10.3 Production of culturally appropriate materials

A primary means of improving understanding about the health issues concerning tobacco use is the development and dissemination of specifically targeted materials, suited to the individual cultural and linguistic needs of each community. Finding the best tone to use is also critical to giving information effectively—for example by using humour and being kind, respectful, and non-judgemental rather than 'preaching or pestering'57—may be a more successful method of communication. Promoting the positive aspects of giving up smoking rather than dwelling on the negative side of tobacco use is also a factor to consider.6

The Forgotten Smokers,112 a report jointly commissioned by the Australian Medical Association and the Australian Pharmaceutical Manufacturers' Association, advised that using 'every-day' Indigenous people as role models, rather than famous individuals who may not perceived as having to face the everyday stresses of ordinary life, could increase a campaign's effectiveness. Younger smokers in particular were tired of messages promoted by popular Indigenous sporting role models.112 Additionally, Indigenous colours and drawing styles, cartoon depictions, humour and simple, directly relevant text were considered likely to improve the appeal and usefulness of resources. Including emphasis on family themes and using story-lines were likely to make messages more powerful.112

Older Indigenous smokers and health workers in particular express a desire for culturally specific materials and feel that mainstream public health messages lack relevance. On the other hand young people, particularly those living in metropolitan areas, are more likely to identify with broader youth culture.36

An additional consideration is variation in cultural beliefs about the origins of ill health. Among individuals in some communities, traditional beliefs about causation of illness (such as being due to sorcery, interpersonal conflict, or the breaking of taboos) may take precedence over the biomedical model.31 For these people, mainstream public health messages concerning the health effects of tobacco use are not relevant.

8.10.4 Positioning tobacco use as a threat to cultural survival

Revival, nurturing and continuation of Indigenous cultural heritage are strong motivating factors for some individuals and communities. Highlighting the connection between not smoking, good health and survival may therefore be a salient message for some Aboriginal and Torres Strait Islander smokers.112 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. Younger smokers in particular have reported an interest in this message—'it's not part of our culture—give it back.'112

8.10.5 Ensuring a clear and salient message

The health messages that appear to have greatest salience among Indigenous smokers are that smoking causes lung cancer, and smoking reduces fitness.112 The reason for this is that the connection between drawing smoke into the lungs and then developing lung disease is easily understood, whereas more complex biological pathways (such as the causation of heart disease or cancers of more remote sites) may not be believable for some smokers, in the absence of a clear explanation of how the disease process occurs. Fitness is seen as being separate to health, and is a particular concern for young males and females, and older males.112

8.10.6 Potential role for Quit support groups and rehabilitation style programs

While 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 led 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.36, 112 The concept of rehabilitation-style programs, like those offered for alcohol and other drug withdrawal, has also been raised as a possibility.6

8.10.7 Community elders, parents and older people as role models

Community influences are key factors in encouraging uptake of smoking and discouraging quitting (see Section 8.9.4) , and children model their behaviours on what they observe around them, and particularly the behaviour of those whom they admire (see Section 8.4.3).

When smoking is highly prevalent, there is an increased likelihood that respected community members are also smokers.6 Parental influence is one of the key influences on uptake of smoking by children. However Australian studies have shown that Indigenous parents who smoke doubt that they can discourage their children from smoking with any degree of credibility.36, 112

Research for the National Tobacco Campaign undertaken in Victoria showed that community respect for elders and older community members means that they may be influential role models, and that without the support of these individuals, cessation programs would be much less effective. The influence of elders appeared more likely to affect the behaviour of other adults than of teenagers. It was recognised, however, that many elders themselves were suffering from ill health caused by tobacco use, and that to encourage their communities to quit, they would need to stop smoking themselves.36 Assisting older smokers to quit might therefore serve the twofold purpose of supporting those most likely to be experiencing ill health due to smoking, and helping to initiate more widespread declines in smoking behaviour.36

8.10.8 Role of health staff

Health workers are critically important to conveying information and providing support to their communities about smoking and health. In turn, they are also seen as role models. 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 8.3.3). Their workload is also stressful, given that they are immersed in communities with the poorest health and welfare outcomes in Australia,112 and operate within time and economic constraints.

These factors probably contribute to an unwillingness to recommend changes in behaviour that they themselves do not practise. Research based in Indigenous health care settings in Queensland found that health workers were reticent about integrating brief intervention advice into consultations because of their smoking behaviour and its normality among the community, the low priority given to tobacco control by the community particularly in the light of other pressing issues such as alcohol abuse, domestic violence and petrol sniffing, and the socioeconomic factors influencing their clients' lives that undermined opportunities to make healthy lifestyle choices.57 A study of Indigenous health workers in the south coast region of New South Wales has reported similar findings.58 As part of its evaluation series, the National Tobacco Campaign examined the opinions of Indigenous community health workers from country and metropolitan Victoria.36 The overall view expressed by those surveyed was that while tobacco caused health problems in the long term, it was eclipsed by more immediate pressures of alcohol and other drug misuse. Some health workers themselves used tobacco to help develop a rapport with their clients, smoking seeming to have 'strong symbolic meaning within the community in terms of both bonding between people and acting as a pacifier.'36 p 244 Several implications were drawn from these findings: that health workers who smoked did not feel they had the right to advise others to quit; that any quit message coming from them would lack credibility; and that if they themselves tried to quit and failed, this would prove that quitting is too hard to attempt.36 Conversely, 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.58

The NATSITCP found that fewer than half of surveyed health staff reported that they had discussed tobacco with clients. They attributed this to a lack of training, resources and time; and also to not feeling comfortable discussing tobacco.6 Part of this may also stem, for some health workers, from cultural reluctance to appear judgemental of their peers, or to act in contravention of traditional law that disallows particular individuals from advising certain others in the community (such as non-family members or elders).57, 115

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.112

The difficulties experienced by health care workers with participating in tobacco control measures are therefore complex and require careful attention: health staff need special support to help them promote smoking cessation. This has been recognised by the New South Wales Government, which has recently announced the launch of a new training program designed to assist Indigenous health workers in delivering cessation programs.117 The Centre for Excellence in Indigenous Tobacco Control is also concentrating its efforts in this area.118

8.10.9 Programs for children

There is strong community support for education programs aimed at children,6 perhaps at least in part because they do not directly target adults.67 Respondents to the NATSITCP 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.6 In communities where school attendance is sporadic, other means of conveying messages to children need to be found. Peer-led education programs may also be effective, as well as the use of positive adult role models.6

8.10.10 Role of remote community shops

The relationship between community stores that serve isolated communities and the provision by tobacco manufacturers and distributors of sales incentives and underwritten freight costs has been identified as a contributor to economic and physical dependency on tobacco.33

Recent research suggests that community shops serving remote communities may potentially assist in tobacco control by supporting health programs, 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.119

8.10.11 Pharmacological assistance—buproprion ('Zyban')
            and nicotine replacement therapies

The NATSITCP found that although there was high awareness of the existence of pharmacological aids to quitting smoking, and particularly of nicotine replacement therapy, 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.6 The provision of free nicotine replacement therapy (NRT) in the form of patches to some communities had led to widespread experimentation, but once the patches had run out, individuals were reluctant to purchase further courses (involving a significant up-front expense). The report makes the observation that while NRT may be contra-indicated for some segments of the population due to underlying medical conditions (such as in those who have suffered stroke) it is likely that with better information, and as part of a comprehensive tobacco cessation program, NRT would achieve higher success rates. The AMA/APMA report, The Forgotten Smokers, has observed that consideration should be given to providing NRT free of charge to Indigenous smokers wanting to quit.112

Studies examining the effectiveness of providing free nicotine patches to Indigenous smokers in communities within the Northern Territory120 and Western Sydney121 have reported a cessation rate after six months of 10% and 9% respectively. A study from the Illawarra and Shoalhaven regions of NSW122 reported a quit rate of 6% at three months following the provision of subsidised NRT. Although these quit rates are lower than those reported for other populations in the medical literature,123 these studies provide evidence that assisted availability of NRT, in combination with appropriate cessation support counselling, could benefit some Indigenous smokers.

Pharmacological adjuncts to smoking cessation are discussed in greater detail in Chapter 7.

8.10.12 Acknowledging and addressing the role of stress

The central role for tobacco use as a means of responding to stress must be recognised given the difficult circumstances in which many Aboriginal peoples and Torres Strait Islanders live.6, 116 121 Stress management is commonly given as a reason for smoking, and the cause of relapse after a quit attempt.121 It is 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.6, 121 The NATSITCIP has emphasised the need for stress to be recognised in its recommendations.6

8.10.13 Secondhand smoke

High smoking rates make exposure to secondhand smoke a health issue for many Aboriginal peoples and Torres Straits Islanders, particularly infants and children (see Section 8.7.6). The AMA/APMA report, The Forgotten Smokers, found that secondhand smoke was an issue of concern to Indigenous smokers, chiefly in relation to its effect on children. Because of the high rates of exposure among children to secondhand smoke, this issue has great potential to have an impact.112 It may also be that building on traditional, culturally important notions of respect for others could have saliency in developing educational messages on this issue, and that encouraging smokers to consider the health of those around them might lead on to questions of smoking and personal health in a less confrontational manner.6

8.10.14 Harm reduction

Roche and Ober have argued that adoption of harm reduction strategies might usefully increase the range of interventions open to health workers in Aboriginal and Torres Strait Islander communities.116 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.

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 (for example by introducing smokefree areas), and monitoring for early signs of smoking-related illness.116 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, and 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.

8.10.15 Exposing tobacco industry tactics

Showing how the Australian and multinational tobacco industry targets smokers, especially the most disadvantaged members of society, may provide another useful angle for information campaigns for Indigenous communities.112 See also Section 8.12 below.