8.1 Aboriginal and Torres Strait Islander peoples: social disadvantage, health and smoking—an overview

Two distinct First Nations people inhabit Australia: Aboriginal and Torres Strait Islander peoples. Initially, Aboriginal peoples lived throughout mainland Australia and Tasmania and on many offshore islands, while Torres Strait Islander peoples inhabited the northernmost peak of the Australian mainland and the islands of the Torres Strait scattered between Cape York Peninsula and Papua New Guinea.¹ Both groups are now less clearly defined by geography; many Torres Strait Islander peoples have moved to mainland Australia for economic reasons,¹ and the Torres Strait region is now home to a substantial population of individuals of both Torres Strait Islander and Aboriginal origin.² There is also enormous diversity among different Aboriginal and Torres Strait Islander communities across the country—diversity in culture, language, and the ways in which these communities experienced colonisation.¹

In 2019, there were about 847,190 Aboriginal and Torres Strait Islander peoples in Australia, making up 3.3% of the total population.^{3, 4} In 2016, 71,900 people identified as being of Torres Strait Islander origin, accounting for about 9% of the Indigenous population.^{4, 5} The majority (81%) of Aboriginal and Torres Strait Islander peoples live in non-remote areas, although proportionately more Indigenous than non-Indigenous people live in remote areas; in 2016, 47% of all people living in very remote areas and 18% of people living in remote areas were Indigenous. More than half of all Aboriginal and Torres Strait Islander peoples reside in New South Wales and Queensland combined (33% and 28% respectively). The Northern Territory is home to 9% of the Indigenous population, but has the highest proportion of residents of Aboriginal and Torres Strait Island origin (30%). In all other states and territories, the combined Indigenous population comprises 6% or less of the total resident population.^{4, 5} Based on national survey data, the subgroup of Aboriginal and Torres Strait Islander peoples who were born before 1972 and who have reported being removed from their families can be used as a proxy measure for the ‘Stolen Generations’. In 2014-15, the estimated number of the Stolen Generations proxy population was 20,900, representing 13.5% of the Aboriginal and Torres Strait Islander population aged 42 and over.⁶ The majority (79%) were living in non-remote areas.⁶ One-third (33%) of Aboriginal and Torres Strait Islander adults reported being a descendent of all people removed.⁶

The experiences of colonisation have shaped the patterns of tobacco use within these communities. While native tobaccos were used in many Aboriginal and Torres Strait Islander communities prior to colonisation, these have largely been replaced by commercially available tobacco and cigarettes, and tobacco production and consumption practices that were common pre-colonisation have been lost in most parts of Australia (see Section 8.2). In 2018–19, 39% of the combined Aboriginal and Torres Strait Islander population aged 15 and over were daily smokers, although there is considerable variation in tobacco use rates by location, age group, and gender (see Section 8.3).⁷ Encouragingly, there has been a significant decline in Aboriginal and Torres Strait Islander smoking rates since the early 2000s.⁴ Nonetheless, smoking is responsible for a substantial proportion of disease and premature death; smoking accounts for 37% of deaths⁸ and 12.1% of the burden of disease⁹ among Aboriginal and Torres Strait Islander peoples—more than any other risk factor. Tobacco is a causal, contributing, or complicating factor in many of the diseases that contribute most to Indigenous mortality and morbidity, including circulatory diseases, cancer, respiratory diseases, diabetes and pregnancy-related conditions (see Section 8.7). Smoking also has an economic and social impact on Aboriginal and Torres Strait Islander communities (see Section 8.8). These findings highlight the enormous health and social gains that will be made by ongoing reductions in smoking prevalence.

Individuals and organisations across multiple sectors and from around the country have been working to reduce smoking rates in Aboriginal and Torres Strait Islander communities for the past 20 years or more. Their efforts have been hampered by poor and unsustained funding, and by the complex challenges facing the health system in delivering healthcare to Indigenous communities more generally. These challenges include: the capacities of health services and workers; inappropriate development or targeting of programs and resources; insufficient involvement of Aboriginal and Torres Strait Islander communities; and the lack of strategic coordinated action (see Section 8.10). In addition, interrelated socio-economic factors (such as income, employment, education, and housing), as well as other social factors (such as incarceration, removal from family, and racism) are important determinants of tobacco use in Aboriginal and Torres Strait Islander communities (see Section 8.3), and can hinder the success of cessation interventions. Stress associated with poor health and socio-economic conditions, as well as from family and community relationships, work expectations, or from racism and marginalisation, contributes to maintaining high smoking rates and relapse (see Sections 8.6 and 8.9).

However, socio-economic factors alone are not sufficient to drive high rates of smoking in Aboriginal and Torres Strait Islander communities; there are also unique social and cultural factors at play (see Sections 8.6, 8.9 and 8.10). Many people living in Aboriginal and Torres Strait Islander communities are exposed to smoking behaviour; this reinforces the behaviour for smokers and encourages smoking uptake among non-smokers (particularly children). The normalisation of tobacco use is reinforced by the communal nature of smoking, and the social obligations to exchange and share tobacco. Smoking is, therefore, a means of reinforcing social relationships and maintaining social cohesion. In this cultural context, extended families can influence the uptake and maintenance of smoking, as well as being influential in smoking cessation.

Although many individuals and organisations have been implementing tobacco action activities, most have not been evaluated due to a lack of funds or expertise, and the small scale of the activities. Evidence as to what works in tobacco action in Aboriginal and Torres Strait Islander communities is, therefore, limited. Tobacco action programs in these communities are currently designed based largely on what is known about the efficacy of tobacco control activities in the general Australian community. It is clear, however, that Indigenous tobacco action programs must also incorporate approaches that take into account the socio-economic realities of peoples’ lives and the unique social and cultural contexts, as well as considering how to overcome challenges within the healthcare delivery system (see Section 8.10 and Section 8.15). Over recent years, there has been a significant commitment to a strategic approach to Aboriginal and Torres Strait Islander tobacco control with accompanying funding, and over the coming years more evidence of best practice in Indigenous tobacco action will become available as new programs are implemented and evaluated.

Comprehensive, multi-component and community-based tobacco action programs are thought to be the most effective, and many such programs are being developed and implemented in Aboriginal and Torres Strait Islander communities across Australia (see Section 8.10). These programs include a mix of individual-, family-, and community-directed activities to ensure maximum coverage and benefit to smokers and non-smokers. Many programs are also being implemented that include components directed towards specific important target groups: young people, pregnant women, Aboriginal health workers, and prison inmates.

Addressing Aboriginal and Torres Strait Islander smoking and health is a national priority at both the national and state/territory levels. The Australian Government has set ambitious targets to reduce smoking rates and improve healthcare as part of the Aboriginal and Torres Strait Islander Health Plan 2013–2023—see Section 8.13.

Relevant news and research

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References for Section 8.1

1. Aboriginal and Torres Strait Islander Commission. As a matter of fact. Answering the myths and misconceptions about Indigenous Australians. Canberra: Commonwealth of Australia, 1998. Available from: http://learnline.cdu.edu.au/tourism/uluru/downloads/matterfact.pdf

2. National Drug Strategy Unit and Ministerial Council on Drug Strategy. Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009. Canberra: Australian Government Department of Health and Ageing, 2006.

3. Australian Bureau of Statistics. Estimates and projections, Aboriginal and Torres Strait Islander Australians, 2006 to 2031. Canberra: Australian Bureau of Statistics, 2019.

4. 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

5. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016.  2018. Available from: https://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001

6. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Stolen Generations and descendants: numbers, demographic characteristics and selected outcomes. Cat. no. IHW 195 Canberra: AIHW 2018. Available from: https://www.aihw.gov.au/getmedia/a6c077c3-e1af-40de-847f-e8a3e3456c44/aihw-ihw-195.pdf.aspx?inline=true

7. 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

8. Thurber KA, Banks E, Joshy G, Soga K, Marmor A, et al. Tobacco smoking and mortality among Aboriginal and Torres Strait Islander adults in Australia. Int J Epidemiol, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33491081

9. 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