8.3 Prevalence of tobacco use among Aboriginal peoples and Torres Strait Islanders

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Tobacco use is widespread among the Aboriginal and Torres Strait Islander populations34, 35 (Table 8.1). This is likely to be substantially attributable to the well-established correlation of smoking with socioeconomic disadvantage, but also reflects cultural aspects particular to these communities, including the traditional customs of sharing and kinship bonding,6, 7, 36 discussed further below.

The first major national study measuring smoking prevalence in the Indigenous population was the National Aboriginal and Torres Strait Islander Survey (NATSIS) of 1994,37 subsequently updated with the National Aboriginal and Torres Strait Islander Social Survey (NATSISS) of 2002.34 National baseline data on drug use among urban Aboriginal and Torres Strait Islander peoples were also collected in 1994 as a supplement to the National Drug Strategy Household Survey (NDSHS),38 and successive NDSHS reports in 1998,39 2001,40 and 200441 have included data on tobacco use among these populations. The National Health Surveys (NHS) of 199542 and 200143 also provide data sets, and most recently the National Aboriginal and Torres Strait Islander Health Survey for 2004–05 (NATSIHS) has been added to this series, enlarging on the Indigenous component of the earlier NHS reports.35 Most of the data presented in this section comes from the National Aboriginal and Torres Strait Islander Social Survey 200234 and the National Aboriginal and Torres Strait Islander Health Survey for 2004–05,35 both surveys having comparatively large sample sizes.

Table 8.1 shows smoking rates among Aboriginal peoples and Torres Strait Islanders, by sex and age group, for 2004–05.35 Fifty percent of the combined Aboriginal and Torres Strait Islander population are current smokers, more than twice the prevalence among the Australian population as a whole. Taking into account people who do not smoke daily, but who smoke at least once a week, a total of 52% of the Indigenous population are smokers. Smoking rates have remained stable, virtually identical figures being reported in the previous NATSIS of 1994 (52%)37 and the NATSISS of 2002 (51%).34[1]

For all age groups among both men and women, this population group has a substantially higher prevalence of smoking compared to the overall Australian population.44 Highest rates of smoking are among males and females aged between 25–44. Overall, males have a slightly higher prevalence of smoking than females (51% compared to 49%).35 The National Aboriginal and Torres Strait Islander Health Survey 2004–05 found no statistical significance between the prevalence of smoking among Aboriginal peoples and Torres Strait Islanders, although earlier national studies have reported a higher prevalence among Aboriginal peoples.34, 45

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.[2]

8.3.1 Socioeconomic and cultural factors

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

Although there have been some improvements since the NATSIS survey of 1994,37 Aboriginal peoples and Torres Strait Islanders are still significantly more likely to be disadvantaged than non-Indigenous people.34 In 2002, adjusting for size and composition of the household, average gross household income for Indigenous persons aged 18 and over was 59% of that of non-Indigenous persons ($394 per week compared with $665).4 In remote areas, income for Indigenous persons was only about half that of non-Indigenous persons (53%). Many depend on government transfers (benefits) as their major source of income. Members of the Indigenous community have higher rates of unemployment, lower rates of home ownership, and achieve poorer education levels than non-Indigenous Australians.4

Moreover, individuals from Aboriginal and Torres Strait Islander backgrounds are over-represented among those Australians who experience mental illness (as evidenced by higher rates of hospitalisation for mental illness and death and injury through suicide and intentional injury), homelessness and exposure to the prison system,4 each factor being 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 socioeconomic factors, as they do in the general Australian population. The NATSIHS survey of 2004–05 found that smoking was more prevalent among the less educated, the unemployed, individuals renting rather than owning or buying their own home, and those in the lower income brackets.46 Table 8.2 presents these findings, with data for the non-Indigenous population from the National Health Survey of the same year included for comparison.46 Indigenous demographic groups have a higher smoking prevalence than broadly similar demographic groups for the total Australian population (see also Chapter 1, Table 1.5). [3][4][5]

Experiencing more than one life stressor[6] 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, as were reporting higher levels of psychological distress[7] or having a disability or other long term health condition.46

The cultural history associated with tobacco use in these populations is also an important contributing factor to ongoing patterns of usage, as outlined in Section 8.2. In a detailed analysis of the NATSIS survey of 1994,45 several cultural factors were identified which were significantly related to smoking behaviour among the Aboriginal and Torres Strait Islander communities. Some of these data are summarised in Table 8.3.

Males who spoke English as their first language were less likely to smoke than males who did not, while the reverse was true for women. Men and women who considered the role of elders in their communities to be important were more likely to be smokers, as were those who recognised their homelands, and those taken away from their families as a child.45

The findings of the 2002 NATSISS survey showed no decline in the indicators of cultural retention,34 but how these data correlate with the findings for smoking prevalence from the same survey have not yet been analysed. The need for culturally appropriate tobacco control programs has been clearly documented by the National Aboriginal Community Controlled Health Organisation6 and in other recent reports,36, 49, 50 and forms a key recommendation in the current National Tobacco Strategy.21

8.3.2 Geographical factors

While 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. Indigenous people living in major cities are less likely to smoke than those living in very remote areas (49% compared with 52%), and there are differences in prevalence among the states and territories as well (Table 8.4).35

More striking, however, are the variations in smoking behaviour between smaller regions and individual communities. The NATSIS survey from 199437 examined prevalence of smoking as defined by Aboriginal and Torres Strait Islander Commission (ATSIC) region.[8] This survey showed that smoking rates among males were lowest in the Alice Springs ATSIC region (39%) and highest in the Bourke ATSIC region (80%), while for women the lowest smoking prevalence was 17% in the Tennant Creek region and the highest was 69% in the Ballarat region.

Other regional and community-specific surveys have also demonstrated a wide variability in smoking behaviour. For example, studies have confirmed higher rates of smoking in the 'Top End' of the Northern Territory than for the Indigenous population as a whole;52, 53 and a study of Torres Strait Islander people dwelling in far north Queensland found an overall smoking prevalence of 45%, which is lower than the overall Indigenous smoking rate, but a much higher prevalence of smoking (63%) among men aged between 15–34.54

Readers interested in examining earlier regional prevalence surveys are referred in the first instance to the comprehensive literature review by Ivers,7 which provides a summary of research undertaken up until 1999.

8.3.3 Prevalence of smoking among health workers

A range of small surveys6, 55-58 and anecdotal evidence36 suggest that as with their communities, Aboriginal and Torres Strait Islander health workers have a substantially higher prevalence of smoking than the general Australian population. Findings have ranged between 38–46%,56, 57 and up to about 63%.55, 58 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.6 Research has found that many Indigenous health workers who smoke, smoke heavily,56 and that tobacco use provides a means of coping with the stressful nature of their workloads.56, 58 These studies indicate a need for appropriate support and education for health workers as well as the communities in which they work. See Section 8.10.8 for further information on the role of Indigenous health workers in tobacco control.

8.3.4 International comparisons with other Indigenous peoples

International research has shown that some other Indigenous groups use tobacco at significantly higher levels than the background population. For example, in New Zealand 45% of the Maori population are smokers, compared to 21% of the non-Maori, non-Pacific Islander population (2006 data);59 in the United States of America, 32% of American Indians and Alaska Natives are current smokers, compared with 21% of the overall adult population (2005 data);60 and 51% of Canada's off-reserve Aboriginal people are smokers, almost double the prevalence of the non-Aboriginal population for the same year (2000/01 data).61 Although it is likely that these higher prevalence figures are to some extent due to socioeconomic disadvantage,62 the Indigenous experience of marginalisation, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent shift to Western habits and practices are also central to patterns of drug use and ill health.12, 17, 63