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

Two distinct Indigenous populations inhabit Australia: Aboriginal peoples and Torres Strait Islanders. Initially, Aboriginal peoples lived throughout mainland Australia and Tasmania and on many offshore islands, while Torres Strait Islanders 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 Islanders 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 The experiences of colonisation have shaped the ongoing socio-economic disadvantage, poorer health status, and, to some extent, 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tobaccos were used in many Aboriginal and Torres Strait Islander communities prior to colonisation, these have largely been replaced by commercially available tobacco and cigarettes, and tobacco production and consumption practices that were common pre-contact have been lost in most parts of Australia (see Section 8.2).

In 2014, there were about 713,600 Aboriginal and Torres Strait Islander people in Australia, making up 3.0% of the total population.³ In 2011, 63,700 people identified as being of Torres Strait Islander origin, accounting for about 10% of the Indigenous population.³ The majority (79%) of Aboriginal peoples and Torres Strait Islanders live in non-remote areas, although proportionately more Indigenous than non-Indigenous people live in remote areas; in 2011, 45% of all people living in very remote areas and 16% of people living in remote areas were Indigenous. More than half of all Indigenous people reside in New South Wales and Queensland combined (32% and 29% respectively). The Northern Territory is home to 10% 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 5% or less of the total resident population.³

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 Indigenous population aged 42 and over.⁴ The majority (79%) were living in non-remote areas.⁴ One-third (33%) of Indigenous Australian adults (aged 18 and over) reported being a descendent of all people removed.⁴

From a population perspective and according to a broad range of social and economic indicators, Aboriginal peoples and Torres Strait Islanders are by far the most disadvantaged social group in the Australian population. The ratio of Indigenous to non-Indigenous average income is about 0.7.⁵ Indigenous Australians are more likely to occupy overcrowded or otherwise substandard housing, to be unemployed, to attain lower levels of formal education, and to have poorer access to facilities and services than other Australians.^3,6 Members of these communities are also more likely to be exposed to violence, to come into contact with the criminal justice system as victims or offenders, and to be over-represented in the prison system.^3,6 In 2014, 27% of the total adult prisoner population were Indigenous.³ Contributing to and compounding these adverse outcomes are the ongoing traumas of dispossession, cultural dislocation, racism, and separation of families experienced by many individuals and communities.^1,7,8

Aboriginal peoples and Torres Strait Islanders also have poorer health outcomes than the rest of the Australian population.^9,10 Much of the burden of ill-health is attributable to chronic diseases, including diabetes, and heart and respiratory conditions. For the period 2010–12, life expectancy at birth for members of Aboriginal and Torres Strait Islander communities was estimated to be 69.1 years for males and 73.7 years for females, compared to 79.7 years for males and 83.1 years for females for non-Indigenous Australians.³ This pattern of ill-health is not unique to Australia’s Indigenous peoples. Indigenous populations in New Zealand, the United States, and Canada have also experienced significantly higher mortality rates than the general populations. However, the reductions in health inequality seen in these countries since the 1970s are not apparent in Australia.¹¹  Between 2005–2007 and 2010–2012, there has only been a small decline in the life expectancy gap between Indigenous and non-Indigenous Australians of 0.8 years for men and 0.1 years for women.³ 

The poorer health outcomes for Aboriginal peoples and Torres Strait Islanders are partly attributable to the high rates of tobacco use in these communities. Smoking accounts for 20% of Indigenous deaths and 12.1% of the burden of disease—more than any other risk factor.¹² 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).

In 2014–15, 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).  After adjusting for differences in age structure, Indigenous people were almost three times more likely than non-Indigenous people to be daily smokers.¹³ Encouragingly, there has been a significant decline in Indigenous smoking rates since the early 2000s; however, the gap in smoking rates between Indigenous and non-Indigenous Australians has remained stable.³ 

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 Indigenous 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 Indigenous 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 in some way; 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). Over recent years, there has been a significant commitment to a strategic approach to Indigenous 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 Indigenous inequalities in smoking and health is a national priority at both the national and state/territory levels. The Council of Australian Governments has committed to ‘closing the gap’ in Indigenous health outcomes, and has an ambitious target to reduce smoking rates. Each jurisdiction has developed implementation plans that are closely related to the strategies and targets articulated in their tobacco strategies or action plans (see Section 8.13).

Relevant news and research

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References

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 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

4. 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. 

5. Biddle N. CAEPR Indigenous population project 2011 census papers: Income. Census paper no. 11, 2013, Centre for Aboriginal Economic Policy Research: Canberra. Available from: http://caepr.anu.edu.au/sites/default/files/cck_indigenous_outcomes/2013/07/2011CensusPaper11_Income%20upd.pdf .

6. Australian Government Productivity Commission. Overcoming Indigenous disadvantage: Key indicators 2009. Canberra: AGPC, 2009. Available from: http://www.pc.gov.au/research/ongoing/overcoming-indigenous-disadvantage/keyindicators2009 .

7. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander tobacco control project final report. Canberra, Australia: National Aboriginal Community Controlled Organisations, 2002.

8. Ivers R. Indigenous Australians and tobacco—a literature review. Darwin, Australia: Menzies School of Health Research and the Co-operative Research Centre for Aboriginal and Tropical Health, 2001. Available from: https://www.lowitja.org.au/sites/default/files/docs/Indigenous_Australians_and_Tobacco.pdf .

9. 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, 2010  Canberra: ABS, 2010. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4704.0 .

10. 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

11. Ring I and Firman D. Reducing Indigenous mortality in Australia: Lessons from other countries. Medical Journal of Australia, 1998; 169:528–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9861910

12. 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 .

13. 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