The early sections of this chapter present a range of unique historical and socio-economic reasons contributing to higher rates of smoking among Aboriginal and Torres Strait Islander communities. There are a number of social and cultural factors that also contribute to maintaining high smoking rates in Aboriginal and Torres Strait Islander communities. The most influential of these are discussed further below: the role of smoking as an alleviator of stress, and the normative nature of smoking within these communities—socialising around the smoking activity and sharing tobacco are crucial in reinforcing relationships and maintaining social cohesion. These factors that motivate or maintain smoking behaviour, in turn become deterrents to quitting.
Studies have reported that the most commonly cited reason for smoking is as a means of alleviating stress and as a way of signalling a few personal moments of 'time out'.1–9 In this way, Aboriginal and Torres Strait Islander smokers are similar to non-Indigenous smokers, who also nominate stress relief as among the reasons they smoke.10 The Forgotten Smokers, a study of Indigenous smoking undertaken in 2000, found that respondents liked and valued smoking because unlike anything else in their lives, it reliably produced a relaxing and calming effect.2 However, the way stress is experienced by Indigenous people is profoundly different from the stress experience for many non-Indigenous people, and has implications for their smoking behaviour. Other than the stress caused by socio-economic conditions (e.g. low income, housing problems and unemployment), stressors cited in studies of Indigenous smokers include: family and work expectations and responsibilities; relationship problems and family violence; racism; and life-altering events, such as deaths in the (extended) family. 3–9 A study that followed the quit attempts of 32 smokers attending an Aboriginal health service found that the main barriers to achieving smoking cessation were the multiple and intercurrent life stressors that caused them to relapse.3 Several studies of pregnant Indigenous women have also found stress to be strongly associated with smoking; pregnant women have reported needing to smoke in order to relieve their stress, and seeing stressful events as triggers to relapse.4–7 The role of tobacco use in alleviating stress and negative feelings gives smoking value in communities experiencing high levels of daily hardship.
Several studies of the social context of Indigenous smoking reinforce the anecdotal evidence that strong social norms support smoking in Aboriginal and Torres Strait Islander communities.1,4,11 Smoking has been found to be a mechanism to maintain and strengthen kinship bonds and social relationships, and to enhance a sense of belonging and social cohesiveness. Social relationships are strengthened through the communal nature of smoking behaviour as well as through the exchange of cigarettes. The National Aboriginal and Torres Strait Islander Tobacco Control Project, through surveys and focus group discussions with community members and health staff across Australia, reported that the second most common reason cited for smoking was to be around other smokers. In particular, sharing cigarettes was seen as a normal part of the culture, whereas non-smokers felt alienated from the group, partly because they were missing out on the sharing of 'the best information' and gossip.1 Family members who smoke have been found to be influential in the initiation to smoking and in maintaining smoking behaviour, although they can also be influential in quitting.11 Socialising over cigarettes has also been reported by Aboriginal health workers as a way of developing rapport with clients and of debriefing with work colleagues.1,12
Where smoking is commonplace, it serves as a way of identifying oneself with the group and enhancing social interactions. The special cultural connotations of tobacco use for Aboriginal and Torres Strait Islander communities strongly reinforce the behaviour. Within this setting, quit attempts are often undermined by others in the group1,2,4,12 and abstinence can result in a sense of exclusion. Several participants in one study on the social context of smoking reported being derided for their decision to quit, and felt that the only way to quit would be to distance themselves from their family.11 In a qualitative study in Western Australia, pregnant Indigenous women reported the difficulties they had quitting when their families, particularly partners, were not supportive, and when everyone around them was smoking.4 Having a partner who smokes, or living in a household with smokers, is significantly associated with Indigenous women smoking during pregnancy.5,13
Other reasons for smoking that have been reported are as a way to relieve boredom, out of routine or habit (including when drinking alcohol, gambling or having a cup of tea or coffee), and addiction.1,2,4,6 Smoking has also been seen as an aid to weight loss (sometimes, ironically, in response to health advice to reduce weight due to other medical conditions such as diabetes or heart disease).1 One group interviewed reported that smoking was used as a way of curbing appetite, because they did not feel like cooking, or because there was no money for food.1 Projects with young people have also found that youth attitudes include smoking to look older, tougher or cool,14 and wanting to be like older children or parents.15
While smoking rates are high in Aboriginal and Torres Strait Islander communities, 53% of Aboriginal people and Torres Strait Islanders do not smoke, and 34% have never smoked.16 Very few studies have examined why some Aboriginal peoples and Torres Strait Islanders never take up smoking, but knowing this could be helpful in planning prevention activities. Young people in a study in Melbourne cited not wanting to be dependent on cigarettes, having seen harmful effects on the health of family members, and fearing that smoking would affect their fitness for sport.17 In another study in Maningrida, young people who did not smoke stated their main reasons as adverse effect on health, being too young, fear of getting into trouble, and not enjoying it.15 Non-smoking family role models and personal resilience and determination have been cited as influential in not taking up smoking.15,11 Other factors associated with reduced likelihood of initiation to smoking are discussed in Section 8.4.3.
The main reasons for quitting are health considerations, particularly considering both the direct and indirect impacts on the health and wellbeing of children. Other reasons include objections to the smell of the smoke (mainly from women) and the financial cost of buying cigarettes.2,4 The reasons why Aboriginal peoples and Torres Strait Islanders quit are detailed in Section 8.6.
Research has shown that Aboriginal and Torres Strait Islander communities have a good understanding of general health problems associated with smoking, but less knowledge of the specific harmful effects, though as with smoking prevalence there would be regional variation in levels of understanding. National research undertaken by the National Aboriginal and Torres Strait Islander Tobacco Control Project1 during 2001 found that more than 90% of respondents agreed that smoking was dangerous to health and caused a range of illnesses, including lung cancer, heart disease, emphysema and asthma, stroke and blood flow problems, blood pressure problems and problems in pregnancy. Knowledge was lower about the dangers of developing oral cancers and complications in diabetics.1 Studies involving pregnant Indigenous women have reported that they are aware of the general negative health impacts of smoking, but have limited knowledge of how smoking impacts on specific illnesses and on the health of the foetus.4,5,7 Similarly, a study of youth in Melbourne found that most were aware that smoking was bad for their health, but were not aware of the impacts on specific diseases.17 A small qualitative study of young people in Victoria found that 75% were aware of the ill effects of smoking, particularly the effects on their sporting performance.14 More than 60% of young people responding to a school-based survey knew about the effect of smoking on fitness and the heart, the risks associated with passive smoking, the relationship between smoking and lung cancer and respiratory symptoms, and the harmful effects of smoking to the health of adults. Fewer than 60% answered questions correctly about the contents of cigarettes, and the effect of smoking on life expectancy.15
While awareness of the health effects of smoking may generally be good, the National Aboriginal and Torres Strait Islander Tobacco Control Project report points out that a good understanding of the health dangers of smoking does not necessarily translate into quitting behaviour.1 The socio-economic and cultural factors that reinforce smoking in Indigenous communities may simply provide barriers that are too difficult to overcome. In one study of pregnant Indigenous women in New South Wales, around 75% of participants felt that quitting increased the chance of having a healthy baby, but 30% thought that quitting would be harder when pregnant, and 30% thought that there would be no point in quitting if they were exposed to a lot of environmental tobacco smoking anyway.18 Widespread self-exemption through a 'she'll be right' attitude, coupled with the long latency period for many of the diseases caused by smoking, also affect attitudes to quitting.2
There was also a high awareness of the fact that secondhand smoke is dangerous to health, although communities involved in the National Aboriginal and Torres Strait Islander Tobacco Control Project gave mixed reports about whether it had instigated behavioural change. Levels of awareness were likely to be higher among those employed in workplaces that had introduced smokefree policies, but this only influenced those in employment.1 Ex-smokers in several studies report that the impact of smoking on others, particularly children, has motivated them to quit.2,11,14 Aboriginal health workers have reported that smokers are more likely to respond to cessation interventions that appeal to their desire to protect those around them, particularly children. They have also reported feeling more comfortable delivering these less confrontational messages.4,8 Given the high smoking rates among Indigenous people, it is probable that secondhand smoke is a serious contributor to ill-health, especially for children (see Section 8.7.4).
Aboriginal peoples and Torres Strait Islanders are impacted by such a large range of complex health and social issues that smoking often takes a lower priority both in the health service and broader community context.2,12 Indeed in one Western Australian study, Aboriginal health workers (n=36) ranked tobacco as the fourth 'biggest problem' (out of five options) behind diabetes, heart disease and alcohol, although they did classify it as a 'serious' or 'very serious' problem for their communities.19 People often attend at health services affected by acute social and health issues that need to be attended to first; health workers report being reluctant to provide smoking cessation advice in the context of so many competing and more immediate issues.4,20
In addition, while 75% of the respondents in the National Aboriginal and Torres Strait Islander Tobacco Control Project study believed that smoking was a big health problem,1 it was nonetheless relegated as a priority behind alcohol or illicit drugs, which present as a more immediate problem, both at community1,12 and service levels.1 Some individuals expressed the view that smoking was an acceptable alternative to other drug use.1 Other studies have also shown that tobacco is ranked behind alcohol and other drugs by Indigenous communities.2,12,21,22
Interestingly, the National Aboriginal and Torres Strait Islander Tobacco Control Project found that respondents tended to overestimate the prevalence of smoking in their communities. Given that the perception of high levels of smoking behaviour is seen as an impediment to quitting,1,12 there may be value in informing communities of the true prevalence of smoking, and that a significant number of Aboriginal peoples and Torres Strait Islanders choose not to smoke.1 Other recommendations supporting quitting activities are discussed in Section 8.10.
1. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander Tobacco Control Project final report. Canberra: National Aboriginal Community Controlled Organisations, 2002. Available from: http://www.naccho.org.au/Files/Documents/NACCHO_Tobacco_report.pdf
2. Stewart I and Wall S. The forgotten smokers. Aboriginal smoking: issues and responses. Commissioned by the Australian Medical Association and Australian Pharmaceutical Manufacturers' Association. Canberra: Australian Medical Association, 2000. Available from: http://ama.com.au/node/778
3. DiGiacomo M, Davidson P, Davison J, Moore L and Abbott P. Stressful life events, resources and access: key considerations in quitting smoking at an Aboriginal Medical Service. Australian and New Zealand Journal of Public Health 2007;31(2):174-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17461010
4. Wood L, France K, Hunt K, Eades S and Slack-Smith L. Indigenous women and smoking during pregnancy: knowledge, cultural contexts and barriers to cessation. Social Science & Medicine 2008;66:2378–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18313186
5. Gilligan C, Sanson-Fisher R, D'Este C, Eades S and Wenitong M. Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women. Medical Journal of Australia 2009;190(10):557–61. Available from: http://www.mja.com.au/public/issues/190_10_180509/gil10102_fm.html
6. Heath D, Panaretto K, Manessis V, Larkins S, Malouf P, Reilly E, et al. Factors to consider in smoking interventions for Indigenous women. Australian Journal of Primary Health 2006;12(2):131–5. Available from: http://www.publish.csiro.au/paper/PY06032.htm
7. Passey M, Gale J, Holt B, Leatherday C, Roberts C, Kay D, et al. Stop smoking in its tracks: understanding smoking by rural Aboriginal women, Conference paper. The 10th National Rural Health Conference. Cairns, Australia: National Rural Health Alliance, 2009. Available from: http://10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf
8. Mark A, McLeod I, Booker J and Ardler C. Aboriginal health worker smoking: a barrier to lower community smoking rates? Aboriginal and Islander Health Worker Journal 2005;29(5):22–6. Available from: http://search.informit.com.au/documentSummary;dn=132032641548770;res=E-LIBRARY
9. Kerdel K and Brice G. Exploring the smokescreen—reducing the stress: action research on tobacco with Aboriginal primary health care workers in Adelaide. Adelaide: Aboriginal Health Council of South Australia, 2001.
10. Carter S, Borland R and Chapman S. Finding the strength to kill your best friend: smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: http://old.tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf
11. Johnston V and Thomas D. Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors. Social Science & Medicine 2008;67(11):1708–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18938006
12. Murphy M and Mee V. Chapter 6: The impact of the National Tobacco Campaign on Indigenous communities: a study in Victoria. In Hassard, K, eds, Australia's National Tobacco Campaign: evaluation report vol.1. Canberra: Department of Health and Aged Care, 1999. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-metadata-tobccamp.htm/$FILE/tobccamp_g.pdf
13. 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
14. Alford K. Koori Community Smokescreen: cigarette use and attitudes in the Goulburn Valley. Aboriginal and Islander Health Worker Journal 2004;28(6):30–2. Available from: http://search.informit.com.au/documentSummary;dn=148038363859564;res=E-LIBRARY
15. Johnston F, Beecham R, Dalgleish P, Malpraburr T and Gamarania G. The Maningrida 'Be Smokefree' project. Health Promotion Journal of Australia 1998;8:12-17. Available from: http://search.informit.com.au/documentSummary;dn=459887031427789;res=IELHEA
16. Australian Bureau of Statistics. 4714.0 National Aboriginal and Torres Strait Islander Social Survey 2008. Canberra: ABS, 2009. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4714.02008?OpenDocument
18. Passey M, Gale J, Stirling J and Sanson-Fisher R. Tobacco, cannabis and alcohol: changes in pregnancy among Aboriginal women in NSW, Conference paper. Primary Health Care Research Conference. Darwin, Australia 2010: Adelaide: Flinders University Primary Health Care Research & Information Service, 2010. Available from: http://www.phcris.org.au/download.php?id=6874&spi=3
19. Pilkington A, Carter OBJ, Cameron AS and Thompson SC. Tobacco control practices among Aboriginal health professionals in Western Australia. Australian Journal of Primary Health 2009;15(2):152–8. Available from: http://www.publish.csiro.au/?paper=PY08066
20. Harvey D, Tsey K, Cadet-James Y, Minniecon D, Ivers R, McCalman J, et al. An evaluation of tobacco brief intervention training in three Indigenous health care settings in north Queensland. Australian and New Zealand Journal of Public Health 2002;26(5):426–31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12413286
21. 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
22. Franks C. Gallinyalla: a town of substance? A descriptive study of alcohol, tobacco, medicines and other drug use in a rural setting. Rural and Remote Health 2006;6(2):491. Available from: http://www.rrh.org.au/publishedarticles/article_print_491.pdf