|Last updated: August 2016
Suggested citation: van der Sterren, A, Greenhalgh, EM, Knoche, D, & Winstanley, MH 8.9 Attitudes to and beliefs about 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/chapter-8-aptsi/8-9-attitudes-to-and-beliefs-about-smoking
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 have been very important in reinforcing relationships and maintaining social cohesion. These factors that motivate or maintain smoking behaviour in turn become deterrents to quitting.
The most commonly cited reason for smoking among Indigenous Australians 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 and other vulnerable groups, who also nominate stress relief as among the reasons they smoke and as a barrier to smoking cessation.10-11 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 gave a perceived relaxing and calming effect.2 National survey research in 2012–13 found that more than four in five Indigenous Australians agreed that smoking calms them down when stressed.12 However, the way stress is experienced by Indigenous people can be 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.3-5,7-9 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 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.1,4,13 A study in the ACT used social network analysis to find that exposure to smokers in one’s social network and having a best friend who smoked strongly influenced whether a person was a smoker.14 The Talking About The Smokes (TATS) project undertaken in 2012–13 found that Aboriginal and Torres Strait Islander smokers are less likely than smokers in the general population to believe that society views smoking as socially unacceptable. This belief likely has a reciprocal relationship with prevalence, such that it may be a product of and also promote higher smoking rates. Perceiving lower levels of social acceptability was associated with wanting and trying to quit.15
Smoking has also 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 others taking up smoking and maintaining smoking behaviour, although they can also be influential in quitting.15
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;1,16 although more recent research in 2012–13 has shown that most Indigenous health workers believe that being a non-smoker sets a good example to patients, and avoid smoking with or around them.17 Research in 2012 found that the normalisation of smoking in Indigenous communities was an overarching barrier to cessation among health workers, with smoking often a part of the workplace culture, and limited smokefree places or policies.18 Where smoking is commonplace, it serves as a way of identifying oneself with the group and enhancing social interactions, and reinforcing the behaviour. Within this setting, quit attempts are often undermined by others in the group1,2,4,16 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.13 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.5,19 Indigenous women interviewed in NSW suggested that pregnant women might risk social isolation by quitting, as smoking plays such an important role in social cohesion.20
Data from the Talking About The Smokes project (2015) showed that daily smokers were less likely than those in the general population to report enjoying smoking and more likely to disagree that smoking is an important part of their life. Indigenous non-daily smokers generally held less positive attitudes towards smoking compared with Indigenous daily smokers, and ex-smokers who had quit within the past year reported positive views about quitting. About one third perceived smoking to be an important part of their life, which was negatively associated with quitting. These findings suggest that factors other than personal attitudes (such as social norms) may be responsible for the high continuing smoking rate in this population.12
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,21 and wanting to be like older children or parents.22
While smoking rates are high in Aboriginal and Torres Strait Islander communities, 53% of Aboriginal and Torres Strait Islander adults do not smoke, and 31% have never smoked.23 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.24 In another study in Maningrida in the Northern Territory, 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.22 Non-smoking family role models and personal resilience and determination have been cited as influential in not taking up smoking.13,22 Other factors associated with reduced likelihood of initiation to smoking are discussed in Section 8.4.3.
Interviews with a national sample of Indigenous Australians in 2012–13 found that among the daily smokers, about four in five regretted starting to smoke and reported spending too much money on cigarettes, both of which were positively associated with wanting and trying to quit.12 Other research has found that key reasons for quitting among Indigenous Australians are health considerations, particularly considering both the direct and indirect impacts on the health and wellbeing of children and families. 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; however as with smoking prevalence there is likely regional variation in levels of understanding. National research undertaken by the National Aboriginal and Torres Strait Islander Tobacco Control Project 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 The Talking About The Smokes project also found that most Indigenous daily smokers demonstrated knowledge that smoking causes lung cancer, heart disease, and low birthweight, but fewer were aware that it makes diabetes worse.25 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.24 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.21 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.22
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 Knowledge of direct harms of smoking was not associated with wanting to quit and having attempted to quit in the past year among the TATS project participants.25 In one study of pregnant Indigenous women in New South Wales, about 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 secondhand tobacco smoking anyway.26 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 is also a high awareness of the fact that secondhand smoke (SHS) is dangerous to health. Almost all daily smokers interviewed for the TATS project reported knowing that SHS is dangerous to non-smokers and children, and that it causes asthma in children. Levels of knowledge among daily smokers were lower than among nondaily smokers, ex-smokers and never-smokers.25 Levels of awareness have been shown to be higher among those employed in workplaces with smokefree policies, but this only influenced those in employment.1 Communities involved in the National Aboriginal and Torres Strait Islander Tobacco Control Project gave mixed reports about whether such knowledge had instigated behavioural change,1 while in the TATS project, greater knowledge of SHS harms was associated with health worry, wanting to quit, and having attempted to quit in the past year among smokers, unlike knowledge of direct harms.25 Ex-smokers in several studies report that the impact of smoking on others, particularly children, has motivated them to quit.2,13,21 Together, these findings suggest that messages regarding health effects may be more effective in promoting quitting-related thoughts and behaviours if they are framed in ways that focus on the health of others.25 Indeed, 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.4,8Given the high smoking rates among Indigenous people, SHS is likely a serious contributor to ill-health, especially for children (see Section 8.7.4).
Aboriginal peoples and Torres Strait Islanders are affected by such a large range of complex health and social issues that smoking can sometimes take a lower priority both in the health service and broader community context.2,16 In one Western Australian study, Aboriginal health workers 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.27 On the other hand, surveys of Aboriginal community-controlled health services (ACCHS) in 2012–13 found that most prioritised tobacco control “a great deal” or “a fair amount”, and all had smokefree policies. Most had staff working on and trained in tobacco control, and they offered extra smoking cessation support for staff.28 While some health workers have reported being reluctant to provide smoking cessation advice in the context of so many competing and more immediate issues,4,29 the ACCHSs reported providing a range of quit-smoking information and activities for clients and the community.28
Among the general community, 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 community1,16 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.2,16,30,31
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,1,16 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 A robust line of social psychological research has demonstrated the effectiveness of communicating normative information to powerfully shape behaviour.32 Other recommendations supporting quitting activities are discussed in Section 8.10.
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