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8.4 Smoking among Aboriginal and Torres Strait Islander children and teenagers

8.4.1 Prevalence

8.4.1.1 National surveys

Data 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.⁴ⁱ

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 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

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 behaviour	12–15 year olds				16–17 year olds
Smoking behaviour	1996	1999	2002	2005	1996	1999	2002	2005
Ever 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

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 surveys

A 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 Victoria^12,13 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 retention^11,14,15 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 surveys^10,11,13and two community-based (i.e. not school-based) surveys^8,12 show smoking prevalence rates that are higher among Indigenous compared to non-Indigenous young people. Findings from the 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 surveysⁱⁱ. 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 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.

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	Total
		Prevalence of 'adolescents who have smoked more than just once or twice' (% rounded)
Indigenous	Males	12	20	26	41	43	27
	Females	12	26	39	50	55	36
	Total	12	23	33	45	49	32
Non-Indigenous	Males	19		35	40	38	29
	Females	19		30	42	31	29
	Total	n/a		n/a	n/a	n/a	29

Source: Zubrick et al 2004⁹ and Zubrick et al 1995¹⁷

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 uptake

According 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

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 behaviour

Aboriginal 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.

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

ii 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.

References

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19. Commonwealth Department of Human Services and Health. National Drug Strategy Household Survey: urban Aboriginal and Torres Strait Islander people's supplement 1994. Canberra: CDHSH, 1994. Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-publicat-stats.htm/$file/ndsatsi.pdf

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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

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8.4 Smoking among Aboriginal and Torres Strait Islander children and teenagers

8.0 Introductory note

8.1 Aboriginal people and Torres Strait Islanders: social disadvantage, health and smoking—an overview

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

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