8.7 Morbidity and mortality caused by smoking among Aboriginal peoples and Torres Strait Islanders

Last updated: October 2016 
Suggested citation: Greenhalgh, EM, van der Sterren, A, Knoche, D, & Winstanley, MH 8.7 Morbidity and mortality caused by smoking among Aboriginal peoples and Torres Strait Islanders. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/8-7-morbidity-and-mortality-caused-by-smoking-amon

This section discusses the major tobacco related 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 2015 edition of The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples;1 and analysis of 2011 morbidity and mortality data in Australian burden of disease study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011.2 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 Islanders

Aboriginal peoples and Torres Strait Islanders experience poorer health outcomes and have a lower life expectancy than the rest of the Australian population—10.6 years lower for men, and 9.5 years lower for women (2010–2012 data). Between 2005–2007 and 2010–2012, the life expectancy gap between Indigenous and non-Indigenous Australians is estimated to have narrowed by 0.8 years for men and 0.1 years for women. For the period 2008–2012, 65% of deaths among Indigenous people occurred before the age of 65, compared with 19% of deaths among non-Indigenous people. The mortality rate for Indigenous people was 1.6 times that of non-Indigenous people (age-standardised rates of 981 and 596 deaths per 100,000, respectively). The largest difference in mortality rates were for people aged 35–44, with male and female Indigenous death rates 3.9 and 4.5 times the non-Indigenous rates, respectively. Over this period, infant deaths represented 4.2% of Indigenous deaths, compared with 0.8% of non-Indigenous deaths. Between 1998 and 2012, the gap in infant mortality rates (i.e., deaths of children under one year old) narrowed by 83%; for Indigenous infants, it fell by 64% (from 13.5 to 5.0 deaths per 1,000 live births), while it fell by 25% for non-Indigenous infants (from 4.4 to 3.3 per 1,000 live births).1 

For the period 2008–2012 in New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined, 75% of deaths among Indigenous people aged 0–74 years were from avoidable causes (i.e., deaths from conditions that could either be prevented from occurring at all, or that could be avoided with early diagnosis and effective treatment), compared with 66% of non-Indigenous deaths in the same age group. Aboriginal and Torres Strait Islander peoples died from all avoidable causes at three times the rate of non-Indigenous Australians; although, encouragingly, there was a 27% decline in the avoidable mortality rate for Aboriginal and Torres Strait Islander peoples in the period 1998 to 2012, and a significant narrowing of the gap. Chronic disease and injury are responsible for the greatest proportion of avoidable Indigenous deaths, and are responsive to both prevention and treatment.3  

In 2010–2012, the leading broad cause of death among Aboriginal peoples and Torres Strait Islanders was cardiovascular disease (CVD), accounting for about 25% of all Indigenous deaths. Indigenous people died from CVD at 1.5 times the rate of non-Indigenous people in 2008–2012, and it was responsible for nearly one-quarter of the mortality gap. The next most common cause of death among Indigenous people was cancer (20%, with lung cancer accounting for 4.9% of such deaths), followed by external causes of injury and poisoning (15%), endocrine, metabolic and nutritional disorders (including diabetes; 9.1%), respiratory diseases (7.6%), and digestive diseases (5.6%). Table 8.7.1 shows the leading specific causes of death for both Indigenous and non-Indigenous people.1

Table 8.7.1
Leading specific causes of death, by Indigenous status, NSW, Qld, WA, SA & NT combined, 2008–2012

Source: The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015: Supplementary tables4

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.5 Adjusting for age, in 2012–13 Indigenous people were 2.3 times more likely than non-Indigenous people to be admitted to hospital. Eighty-four per cent of this difference was due to the substantially higher rates of care involving dialysis among Indigenous Australians (which accounted for 45% of hospitalisations; Indigenous Australians were 10 times as likely as non-Indigenous Australians to be hospitalised for chronic kidney disease). Excluding dialysis, the hospitalisation rate for Indigenous people was 1.2 times the rate for non-Indigenous people. The next most common reasons for hospitalisation were injury and poisoning (7.2%) and pregnancy and childbirth (5.8%). The potentially preventable hospitalisation rate (i.e., hospitalisations that might have been prevented through the timely and appropriate provision and use of population health services, primary care or other non-hospital services) for Indigenous people was 3.4 times the rate for non-Indigenous people.1 

A 2016 study analysed mortality and morbidity data from 2011 to assess the ‘burden of disease’ of various conditions for Indigenous people.2 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 8.7.2 shows the leading causes of DALYs for Indigenous males and females. In 2011, coronary heart disease, alcohol use disorders, and suicide and self-inflicted injuries were the top three contributors to the burden of disease for Indigenous males, while for Indigenous females, the leading causes of burden were anxiety disorders, coronary heart disease, and depressive disorders. Coronary heart disease, anxiety disorders, and diabetes were ranked in the top five diseases for both sexes.  After adjusting for differences in age structure, Indigenous Australians experienced overall burden from disease and injury at 2.3 times the rate of non-Indigenous Australians.2

Table 8.7.2 
Leading 20 specific diseases contributing to total burden (DALY) for Indigenous Australians, by sex, 2011

Source: Australian Institute of Health and Welfare, Table 4.32

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

The Australian burden of disease study provides details on the burden attributable to the leading risk factors for Indigenous Australians. In 2011, tobacco use (including past tobacco use, current use, and exposure to second-hand smoke in the home) accounted for 12.3% of the burden of disease, more than any of the other risk factors, and more than for alcohol and illicit drugs combined.2 This proportion appears largely unchanged from the previous burden of disease study in 2003, when tobacco use accounted for 12.1% of the total burden.6 

In 2011, tobacco use was responsible for 23.3 per cent of the gap in disease burden between Indigenous and non-Indigenous Australians. Coronary heart disease was the leading disease outcome attributable to tobacco use, followed by chronic obstructive pulmonary disease (COPD), lung cancer, and stroke. Tobacco caused 93 per cent of the lung cancer burden, 87 per cent of the COPD burden, 71 per cent of the oesophageal cancer burden, and 64 per cent of the mouth and pharyngeal cancer burden. Across all disease outcomes, the large majority (81 per cent) of the burden was due to premature mortality, although this varied substantially by disease. For example, premature death made up almost all of the attributable liver, oesophageal, and lung cancer burden but only 6 per cent of the asthma burden. The overall burden attributable to tobacco use increased with age, and was greater in males than females.2

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.7 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. 

Two earlier studies also attempted to quantify deaths due to smoking among Indigenous people. These were conducted in the Northern Territory (1986–1995)8 and Western Australia  (1983–1991).9 Although there are methodological weaknesses and the findings should not be generalised to the total Indigenous population, the studies provide 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.8 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.8 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).8

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 leading cause of death, followed by lung cancer and chronic bronchitis.9 Indigenous women died at almost four times the rate of non-Indigenous women (118 deaths per 100,000 compared to 32 per 100,000) and Indigenous men died from tobacco-caused illness at nearly two-and-a-half times the rate of non-Indigenous men (271 deaths per 100,000 compared to 113 per 100,000).9 

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 with 45 years of age;8 the Western Australian report found that nearly half of all tobacco-caused deaths occurred before the age of 55 in the Indigenous population, compared to only about 11% of deaths in the non-Indigenous population.9 

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.10 Although Indigenous males had a slightly higher rate of tobacco-related hospital encounters than Indigenous females, the difference between Indigenous and non-Indigenous 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.10 Similarly high rates have been found in earlier studies in the Northern Territory (1993–1995)8 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.10,12 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.10 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).12 

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 ).12

8.7.3 Diseases and conditions related to smoking

As 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: cardiovascular diseases, cancers, respiratory diseases, diabetes, and pregnancy-related conditions. Circulatory diseases

In 2012–13, 13% of Indigenous Australians aged two and over reported having cardiovascular disease (CVD;  a broad term for a range of diseases affecting the heart and blood vessels), and it was the leading cause of death among Aboriginal peoples and Torres Strait Islanders, accounting for 25% of all deaths.1 The leading specific causes of CVD deaths were ischaemic heart disease (55%), followed by cerebrovascular causes such as stroke (17%);3 smoking increases the risk for each of these conditions.13 CVD was also responsible for the largest percentage (24%) of the mortality gap between Indigenous and non-Indigenous people in 2008–2012; however, between 1998 and 2012, there was a 40% decline in age-standardised death rates due to CVD for Indigenous people, and a 43% decline in the mortality gap. This has been largely due to decreases in deaths from coronary heart disease and cerebrovascular disease.1    

 The high prevalence of smoking, diabetes, obesity and sedentary lifestyle, high blood pressure and cholesterol, and poor nutrition in the Aboriginal and Torres Strait Islander populations contributes to the incidence of cardiovascular diseases in their communities. National5 and regional14–17 studies have shown a high incidence of multiple risk factors for heart disease among the Indigenous population, especially smokers.12 In 2004–05, 30% of current smokers and 37% of former smokers reported having heart or circulatory disease.12 Cancers

State 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. The Australian Institute of Health and Welfare’s 2014 report on cancer in Australia indicated that between 2005 and 2009, the age-standardised incidence rate of all cancers combined was 421 per 100,000 for Indigenous Australians, compared with 443 per 100,000 for their non-Indigenous counterparts.18 However, certain types of cancers have higher incidence rates, and for many cancers higher mortality rates have been reported for Indigenous people.5,19–23 In this time period, lung cancer was the most commonly diagnosed cancer among Indigenous Australians, followed by breast cancer in females, colorectal cancer, and prostate cancer.18 The age-standardised incidence rate was significantly higher for Indigenous than for non-Indigenous Australians for liver cancer (2.8 times as high), cervical cancer (2.3), cancer of unknown primary site (1.8), lung cancer (1.7), uterine cancer (1.6), reflecting Indigenous peoples’ higher rates of smoking and heavy drinking, poorer access to healthcare services, and lower participation in national screening programs (for cervical cancer, which smoking is also a risk factor for). 

Analysis of combined data from the cancer registries of South Australia, the Northern Territory and Western Australia22 also 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.24  Alternatively, some cancers had lower incidence rates among Indigenous Australian (colorectal, breast, non-Hodgkin lymphoma, and prostate), perhaps due to a higher likelihood of being diagnosed at a later stage, when the primary cancer site is no longer apparent. Screening for breast and bowel cancer, and testing for prostate cancer, is also lower among this population, which may lead to lower rates of diagnosis.18 Further, although still lower than for the non-Indigenous population, rates of lymphoma and colorectal cancer increased significantly between 1998 and 2005; in 1998 the Indigenous incidence rate for both cancers was about half that of the non-Indigenous rate, but by 2005 the Indigenous incidence had risen to be only about 20% less than the non-Indigenous rate.25  

Between 2008 and 2012, the age-standardised mortality rate of all cancers combined was significantly higher for Indigenous Australians (221 per 100,000) than for their non-Indigenous counterparts (172 per 100,000). This difference may be due to Indigenous Australians’ higher likelihood of being diagnosed with cancers with poor prognoses (e.g., lung cancer and cancer of unknown primary site) or of being diagnosed at an advanced stage, and being less likely to receive adequate treatment. Lung cancer was responsible for the most cancer deaths (25%) among Indigenous Australians, followed by liver cancer (7%), breast cancer in women (6%) and cancer of unknown primary site (6%). Adjusting for age, the mortality rate was significantly higher for Indigenous Australians for cervical (3.4 times), liver (3.0), lung (1.7), and cancer of unknown primary site (1.5) than for non-Indigenous Australians.18 Earlier data showed that the comparative death rates from lung cancer and lip/mouth/pharynx cancers are higher for Indigenous people than non-Indigenous people.21–23 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).21 These poorer outcomes are suggestive of shortcomings in health services available to these communities, and may also reflect language and cultural barriers.19,26–27 Respiratory diseases

Aboriginal and Torres Strait Islander people experience significantly higher rates of respiratory diseases including asthma, chronic obstructive pulmonary disease (COPD), and pneumonia,3 all of which are directly caused by smoking.13 In 2008–2012, respiratory diseases were the fifth leading cause of death among Indigenous Australians, and such diseases were responsible for 12% of the mortality gap.1 Fifty-three per cent of respiratory deaths among Indigenous Australians were attributed to COPD, 4% to asthma and 19% to pneumonia and influenza.3 As with cardiovascular disease, death rates from respiratory diseases declined significantly between 1998 and 2012 (by 26%) for Indigenous people, with a significant closing of the gap of 39%.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.12 Other contributing factors to respiratory and lung disease include living in dusty regions, or exposure to smoke from wood fires.28 These environmental factors may also be responsible for influencing disease rates in some Indigenous communities. Diabetes

Diabetes is a chronic condition in which blood glucose levels become too high due to the body producing little or no insulin, or being unable to use insulin properly.29 As 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,30 and complications in pregnancy and childbirth.31 The 2014 US Surgeon General’s report concluded that smoking is a cause of diabetes.13 Smokers with diabetes are also at increased risk of illness and premature death, mainly through the development of cardiovascular disease in its various forms.32 Being overweight, having an unbalanced diet and lack of physical activity are major risk factors for developing diabetes,33–34 and each is more common in the Indigenous than the non-Indigenous population,5 and among Indigenous smokers than Indigenous non-smokers.12

In 2012–13, 11% of Indigenous Australians aged 18 years and over had diabetes, while an additional 4.7% were at risk of developing diabetes. After adjusting for age, Indigenous adults were 3.3 times as likely to have diabetes as non-Indigenous adults. In 2008–2012, diabetes was the second leading specific cause of death among Indigenous people (accounting for 7.9% of deaths), and was an associated cause of death for an additional 12.3% of Indigenous deaths. It was either an underlying or associated cause of death in 1 in 5 Indigenous deaths (3.9 times the rate of non-Indigenous people), and was the second leading cause of the mortality gap, with no significant improvements in mortality rates for Indigenous people for diabetes between 1998 and 2012.1 National data show that in 2004–05, more than 1 in 10 (13% of) 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.12 Smoking in pregnancy, and maternal and child health outcomes

As noted in Section 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.24 In 2011, newborns of Indigenous mothers were twice as likely to be of low birthweight compared with newborns of non-Indigenous mothers.35 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.36 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.24 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.37 On this basis, it can be said that maternal smoking in pregnancy may be damaging to the health of at least two generations.38 

Poorer health outcomes 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.5,39 Over the period 2008–12, the average perinatal death rate of babies born to Aboriginal or Torres Strait Islander mothers was about 9.6 per 1,000 births compared with 8.1 per 1,000 births for non-Indigenous babies. Rates among Indigenous women varied substantially by state/territory, from 3.7 deaths per 1,000 Indigenous births in SA, to 18 per 1,000 births in the NT. Overall, the rate decreased by about 52% between the years 1998 and 2012, and by a larger amount in Indigenous than in non-Indigenous Australians, leading to a significant decrease in the gap.3  Medical care improvements such as access to hospital birthing facilities, improved neonatal and paediatric care, and the establishment of pre-natal screening for congenital abnormalities have likely contributed to this decrease.40 The two main causes of death among Indigenous infants were certain perinatal conditions such as birth trauma, disorders related to foetal growth, and complications of pregnancy, labour and delivery (48% of infant deaths), followed by symptoms, signs and ill-defined conditions (19% of infant deaths, mainly from sudden infant death syndrome, or SIDS). The risks of both these categories of problems are elevated by smoking during pregnancy. Other than smoking, factors that affect maternal and child health outcomes include socio-economic circumstances, access to healthcare facilities, and the mother’s age during pregnancy.41 Indigenous mothers are on average younger than their non-Indigenous counterparts, and are more likely to be disadvantaged.5

A limited 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.38 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-smokers; there was no significant difference in birth outcomes between Indigenous and non-Indigenous smokers.42 Other studies of Indigenous birth outcomes have found significant associations between smoking and small for gestational age,43 low birthweight,44 and ‘poor birth outcomes’ (low birthweight and/or preterm).45 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.46 An analysis of 2009–11 perinatal data found that, excluding pre-term and multiple births, smoking was responsible for 51% of low birthweight births to Indigenous mothers, compared with 19% for non-Indigenous mothers. After adjusting for a range of demographic factors, it was estimated that the proportion of low birthweight babies could be reduced by about one quarter if the smoking rate among Indigenous pregnant women was the same as it was for non-Indigenous mothers. Babies born to Indigenous mothers who smoked were 1.4 times as likely to be pre-term as those who did not smoke.3 Research in Queensland found that, after excluding pre-term and multiple births, 76% of Indigenous mothers who gave birth to a low birthweight baby reported smoking during pregnancy.47

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 effects

Secondhand 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.48 The health risks from exposure to secondhand smoke are discussed in detail in Chapter 4.

In 2014–15, about 58% of Indigenous children aged 0–14 lived with a daily smoker: a significant decrease from 63% in 2008. About 13% of Indigenous children lived with someone who smoked inside the home. These proportions increased with remoteness, such that Indigenous children in remote areas were significantly more likely to live with a daily smoker, and to live with a daily smoker who smoked indoors, than those in non-remote areas. Data from 2012–13 showed that Indigenous children were five times more likely than non-Indigenous children to live with a daily smoker who smoked inside the home (16% vs. 3% of non-Indigenous children).1 In terms of older children and adults, 60% of Aboriginal and Torres Strait Islander people aged 15 years and over were living in a household in which there was at least one daily smoker in 2014–15, down from 68% in 2008. Almost one in five (19%) were living in a household in which someone smoked inside.49

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.45 Similarly, a 2015 study detected serum cotinine (which indicates exposure to cigarette smoke) in just over half of a sample of pregnant Indigenous women, and this was negatively associated with birth weight and gestational age at delivery.50 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.51 In a 2013 qualitative study, Indigenous participants described avoiding smoking if children were present, and often limited the household areas where they smoked in an attempt to protect babies and children. Some also reported showering or changing clothes after having a cigarette.52

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.53  A study from Queensland found that 40% of Indigenous infants were exposed to smoke in the home, compared to 20% of non-Indigenous babies.54 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.55 Indigenous children have more than three times the incidence of ear and hearing problems of non-Indigenous children,5 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 (middle ear infection) in Aboriginal children,56 which is common and frequently severe in Indigenous children,57 and is likely one of the key determinants of the high rates of disability and learning difficulties among this population.58 

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).

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.10

Recent news and research

For recent news items and research on this topic, click here (Last updated March 2018) 



1. Australian Institute of Health and Welfare, The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2015. Cat. no. IHW 147. Canberra: AIHW; 2015. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550168 .

2. Australian Institute of Health and Welfare, Australian burden of disease study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series no. 6. Cat. no. BOD 7. Canberra: AIHW; 2016. Available from: http://www.aihw.gov.au/publication-detail/?id=60129557110

3. Australian Health Ministers’ Advisory Council, Aboriginal and Torres Strait Islander health performance framework 2014 report. Canberra: AHMAC; 2015. Available from: https://www.dpmc.gov.au/indigenous-affairs/publication/aboriginal-and-torres-strait-islander-health-performance-framework-2014-report .

4. Australian Institute of Health and Welfare, The health and welfare of australia’s Aboriginal and Torres Strait Islander peoples 2015: Supplementary tables. Cat. No. Ihw 147. Canberra: AIHW; 2015. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550168&tab=2 .

5. 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/abs@.nsf/DetailsPage/4704.02008?OpenDocument .

6. 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: https://www.lowitja.org.au/sites/default/files/docs/Indigenous-BoD-Report.pdf.

7. 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

8. 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 .

9. 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.

10. Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander people. cat. no. IHW 40 Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publications/ihw/40/11503.pdf .

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 Bureau of Statistics, 4722.0.55.004—tobacco smoking—Aboriginal and Torres Strait Islander people: A snapshot, 2004–05 Canberra: ABS; 2007. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/productsbyCatalogue/D030A9BD9BF14B08CA25730E0021BCE1?OpenDocument .

13. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. 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, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf .

14. Leonard D, McDermott R, O'Dea K, Rowley K, Pensio P, et al. 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

15. 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. Hoy W, Norman R, Hayhurst B, and Pugsley D. Health profile of adults in a Northern Territory Aboriginal community, with an emphasis on preventable morbidities. Australian and New Zealand Journal of Public Health, 1997; 21(2):121?6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9161065

17. 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

18. Australian Institute of Health and Welfare, Cancer in Australia: An overview 2014. Cancer series no 90. Cat. No. Can 88. Canberra: AIHW; 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550047 .

19. 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

20. 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: 



21. 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 .

22. 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 .

23. Moore S, O'Rourke P, Mallitt K, Garvey G, Green A, 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

24. 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/ .

25. Zhang X, Condon JR, Rumbold AR, Cunningham J, and Roder DM. Estimating cancer incidence in Indigenous Australians. Australian and New Zealand Journal of Public Health, 2011; 35(5):477–85. Available from: http://dx.doi.org/10.1111/j.1753-6405.2011.00762.x

26. Miller J, Knott V, Wilson C, Cunningham J, Condon J, et al. Aboriginal and Torres Strait Islander cancer control research project. Canberra: Australian Government, 2010. Available from: http://canceraustralia.gov.au/sites/default/files/publications/atsi_cancer_control_research_report1_504af02522aa1.pdf .

27. 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

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

29. Australian Institute of Health and Welfare, Diabetes: Australian facts 2008. Cat. no. CVD 40. Canberra: AIHW; 2008. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468075

30. 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

31. 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

32. 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

33. 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

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

35. Australian Institute of Health and Welfare, Birthweight of babies born to Indigenous mothers. Cat. no. IHW 138. Canberra: AIHW; 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129548202

36. 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

37. 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

38. 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

39. 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

40. Li SQ, Gray N, Guthridge S, Pircher S, Wang Z, et al. Avoidable mortality trends in Aboriginal and non-Aboriginal populations in the Northern Territory, 1985-2004. Australian and New Zealand Journal of Public Health, 2009; 33(6):544–50. Available from: http://dx.doi.org/10.1111/j.1753-6405.2009.00451.x

41. 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

42. 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.ncbi.nlm.nih.gov/pubmed/18976189

43. Panaretto K, Lee H, Mitchell M, Larkins S, Manessis V, 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):163–70. Available from: http://doi.wiley.com/10.1111/j.1467-842X.2006.tb00111.x

44. 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

45. Eades S, Read AW, Stanley FJ, Eades FN, McCaullay D, et al. 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

46. 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: 



47. Khalidi N, McGill K, Houweling H, Arnett K, and Sheahan A, Closing the gap in low birthweight births between Indigenous and non-Indigenous mothers. Queensland: Health Statistics Centre; 2012. Available from: https://www.health.qld.gov.au/hsu/pdf/statbite/statbite46.pdf

48. 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

49. Australian Bureau of Statistics. 4714.0 - National Aboriginal and Torres Strait Islander Social Survey, 2014–15. 2016. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4714.02014-15?OpenDocument

50. Pringle KG, Rae K, Weatherall L, Hall S, Burns C, et al. Effects of maternal inflammation and exposure to cigarette smoke on birth weight and delivery of preterm babies in a cohort of indigenous Australian women. Frontiers in Immunology, 2015; 6:89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25806032

51. Johnston V, Thomas D, McDonnell J, and Andrews R. Maternal smoking and smoking in the household during pregnancy and postpartum: Findings from an Indigenous cohort in the Northern Territory. Medical Journal of Australia, 2011; 194(10):556–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21644912

52. Gould GS, Munn J, Avuri S, Hoff S, Cadet-James Y, et al. “Nobody smokes in the house if there's a new baby in it”: Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia. Women and Birth, 2013; 26(4):246–53. Available from: http://dx.doi.org/10.1016/j.wombi.2013.08.006

53. 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://www.ncbi.nlm.nih.gov/pubmed/10634979

54. 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

55. Johnston F, Beecham R, Dalgleish P, Malpraburr T, and Gamarania G. The maningrida 'be smokefree' project. Health Promotion Journal of Australia, 1998; 8:12–7. Available from: http://search.informit.com.au/documentSummary;dn=459887031427789;res=IELHEA

56. Jacoby PA, Coates HL, Arumugaswamy A, Elsbury D, Stokes A, 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

57. Morris PS, Leach AJ, Silberberg P, Mellon G, Wilson C, et al. Otitis media in young Aboriginal children from remote communities in northern and central Australia: A cross-sectional survey. BMC Pediatrics, 2005; 5:27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16033643

58. DiGiacomo M, Davidson PM, Abbott P, Delaney P, Dharmendra T, et al. Childhood disability in Aboriginal and Torres Strait Islander peoples: A literature review. International Journal for Equity in Health, 2013; 12:7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23327694

      Previous Chapter Next Chapter