8.10 Tobacco action initiatives targeting Aboriginal and Torres Straits Islander peoples

To date, critical evaluations of the various tobacco control programs that have been undertaken among Aboriginal and Torres Strait Islander communities have been sparse, or limited by small sample size and problems with research design. While there is an extensive literature about initiatives aimed at reducing smoking prevalence in other populations and their effectiveness, there is a paucity of evidence that considers the appropriateness and transferability of such initiatives to Aboriginal and Torres Strait Islander contexts. ^1-5 A systematic review of trends in Aboriginal and Torres Strait Islander tobacco research from 2004 to 2013 found that there are still few intervention studies available to guide efforts to reduce tobacco-related health disparities. ⁶ Rigorous evaluations are needed to build the evidence base around tobacco action initiatives in Aboriginal and Torres Strait Islander communities. ⁷

Despite the limited evidence about what works in Aboriginal and Torres Strait Islander tobacco control, ^{8 , 9} several reviews have identified the likely factors critical to the success of designing appropriate tobacco initiatives for Aboriginal and Torres Strait Islander communities. ^{1-4 , 8-16} Important principles that should underpin tobacco action in Aboriginal and Torres Strait Islander communities to enhance program delivery include: ^{1 , 3 , 13 , 14 , 17-19}

• maximising community control, and building capacity within Aboriginal and Torres Strait Islander organisations and communities
• understanding and respecting the social context in which Aboriginal peoples and Torres Strait Islanders live their lives, and ensuring that this is reflected in programs that include a focus on family and community
• developing programs that are holistic in nature and consider the social determinants of health
• drawing on existing theory and research to ensure messages and approaches are evidence-based
• ensuring that tobacco action programs are as comprehensive as possible within given resources
• evaluating all programs with a view to building the evidence of best practice in Indigenous tobacco action
• making sufficient and ongoing funding available to develop sustainable long-term programs
• building cooperative relationships across sectors, while always being mindful of maintaining Aboriginal and Torres Strait Islander community control within these relationships.

A 2016 systematic review examined strategies to reduce commercial tobacco use in Indigenous communities globally. The authors concluded that the breadth of research indicates a growing prioritisation and readiness to address the high rates of smoking among Indigenous peoples. A comprehensive approach comprising multiple activities, Aboriginal leadership, long-term community investments, and the provision of culturally appropriate health materials and activities appear to be important elements for promoting positive change. ²⁰

This section will summarise the current evidence around cessation aids and support in the Aboriginal and Torres Strait Islander context, and provide examples of programs and activities that have been implemented in Aboriginal and Torres Strait Islander communities. Specifically, it will examine evidence regarding:

• Pharmacotherapies, such as NRT, varenicline, and bupropion
• Quitlines
• Support groups
• Telephone and internet support
• Cessation support for Aboriginal Health workers
• Cessation support for young people
• Cessation support for pregnant women, and
• Cessation support for prisoners

The examples given are not exhaustive, and readers interested in knowing more about particular programs in Aboriginal and Torres Strait Islander communities are referred to online resources that provide updated information on programs around the country ⁱ .

See Section 8.15 for an overview of evidence on the role of health workers and community organisations in promoting cessation, and Section 8.14 for the effectiveness of population-level tobacco control strategies.

8.10.1 Considering the context to develop relevant tobacco action programs

If smoking is understood as a ‘socially and culturally patterned behaviour’, then differences between Aboriginal and Torres Strait Islander and non-Indigenous communities in history, social and cultural background and attitudes to health suggest that initiatives that have shown success elsewhere may not all be transferable to Indigenous contexts without at least some degree of modification. ⁵ In addition, there are many nations within Aboriginal and Torres Strait Islander peoples in which the cultures and social practices vary considerably, therefore a ‘one size fits all’ program is unlikely to be successful. Tobacco action within Aboriginal and Torres Strait Islander communities must incorporate approaches that take into account the socio-economic realities of people’s lives and the unique social and cultural contexts, as well as considering how to overcome challenges within the healthcare delivery system that may contribute to reducing the effectiveness of tobacco action initiatives.

The impacts of socio-economic factors on smoking rates for Aboriginal peoples and Torres Strait Islanders have been discussed in Section 8.3. Clearly, tobacco action initiatives must take into account the underlying socio-economic realities facing many Aboriginal and Torres Strait Islander people, and work towards addressing broader social disadvantage. However, it should be noted that the causal pathways between specific variables of socio-economic disadvantage (such as income, education, employment and housing) and smoking are not clear; the pathways are, in fact, likely to be highly complex and interconnected. Simply addressing one or another of these variables is unlikely to have an impact on smoking rates by itself. ²¹

These socio-economic factors also contribute to the complex stressors that Aboriginal and Torres Strait Islander peoples may face in their daily lives. Smoking is commonly perceived as a means of coping with stress (see Section 8.9.1.1). ²² However, smoking appears to increase stress levels, ²³ while quitting is associated with reduced stress, depression, and anxiety; ²⁴ therefore, an additional benefit of cessation may be improving the mental health of Aboriginal and Torres Strait Islander peoples.

Socio-economic factors alone are not, however, sufficient to be driving high rates of smoking in Aboriginal and Torres Strait Islander communities. While smoking does increase along with socioeconomic disadvantage, an analysis of the 2002 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) found that even among those in the highest quintile of household income, smoking prevalence was still at 37%, compared to an overall prevalence of about 51%. ²¹ Clearly, social and cultural factors also play a role in promoting smoking ²⁵ (see Section 8.9.1.2). Given the influence of extended family relationships in the uptake and prevalence of smoking, as well as in quitting, family-centred initiatives based in the home and community are likely to  be an influential part of tobacco action programs in Aboriginal and Torres Strait Islander communities. ²⁵ In addition, community esteem and respect for elders and older community members means that supporting them to quit may contribute to initiating more widespread declines in smoking behaviour through role modelling. ²⁶

Some argue that mainstream public health messages lack relevance for many Aboriginal and Torres Strait Islander people. ^{5 , 26 , 27} Several studies suggest, however, that many mainstream tobacco action activities are acceptable and effective (see Section 8.14). ^{5 , 28 , 29} While modifications of programs may be important, the role of the health system in reducing the effectiveness of tobacco action programs should not be overlooked. ⁵ Barriers in the health system that can affect program efficacy include: workforce turnover; lack of staff training opportunities; the orientation of services towards acute rather than preventive care; and access to and availability of appropriate health services and treatment for Aboriginal and Torres Strait Islander peoples (see Section 8.15). Adequate and sustained funding to the healthcare system specifically for Aboriginal and Torres Strait Islander peoples and specifically directed towards tobacco action has also been cited as necessary for program success. ^{1 , 13 , 30}

8.10.2 Taking a comprehensive approach

Comprehensive tobacco action programs that are likely to have the greatest success in Aboriginal and Torres Strait Islander communities are multi-component, take a whole-of-community approach, are integrated across different activities within health services, and work across different sectors within communities. In mainstream programs, it is well understood that addressing one part of tobacco control in isolation reduces the chances of success. ³¹ For example, the benefits of producing salient health messages are diminished if appropriate training for health staff to provide further information and support in quitting is not provided. Offering access to pharmacological aids to cessation in the absence of creating a supportive structure in which cessation can occur is similarly unlikely to succeed. ³¹ It is likely that a cumulative effect of exposure to low-level or indirect anti-tobacco activities delivered as part of a comprehensive tobacco action program may affect Aboriginal and Torres Strait Islander smokers quitting by themselves; some studies have noted high levels of Aboriginal and Torres Strait Islander smokers who have quit without the use of organised programs or specific help. ^{32 , 33}

It is also important not to treat tobacco use in isolation. Strategies intended to reduce smoking rates will not be effective if planned without reference to community-identified health priorities such as alcohol and other drug misuse, violence, education and employment. Raising standards of living and improving educational and employment opportunities can be expected to enhance overall health outcomes, as well as bringing about declines in smoking. Tobacco interventions need to be part of a multi-level approach that recognises the broader social, economic, and cultural environment of communities. ³⁴ Equally, effective tobacco control strategies that reduce uptake and promote cessation can help address many of these problems, for example by improving mental health ²⁴ and relieving financial stress. ³⁵

Such multi-level, comprehensive approaches are consistent with the principles of Aboriginal and Torres Strait Islander community-controlled primary healthcare and with a holistic view of health. This concept, where health is ‘not just the physical well-being of the individual, but the social, emotional and cultural well-being of the whole community’, ³⁶ and that all aspects—community, land, mind and spirit, the physical and spiritual—are interconnected and interdependent, means that consideration of one element cannot meaningfully occur in isolation from the others. ³⁷ This world view underpins the delivery of healthcare by Aboriginal Community Controlled Health Organisations that ideally focus on comprehensive, integrated and preventive approaches within a framework of community control and self-determination. ³⁸

Many multi-component tobacco action programs have been, or are currently being, implemented in Aboriginal Community Controlled Health Organisations and in Aboriginal and Torres Strait Islander communities. These include: the Tobacco Project; ^{39 , 40} the Top End Tobacco Project (Northern Territory); ^41-44 Clean Air Dreaming (New South Wales); ⁴⁵ Building Research Evidence to address Aboriginal Tobacco Habits Effectively (BREATHE), ⁴⁶ and Tobacco Resistance and Control (A-TRAC) Program (Aboriginal Health and Medical Research Council of New South Wales); ⁴⁷ Our Space Smoke Free (Queensland); ⁴⁸ Deadly Nungas Say No to Puiya (South Australia); ^{49 , 50} Northern Territory Tobacco Project; ³⁰ Goreen Narrkwarren Ngrn-toura (Healthy Family Air) (Victoria); ^{15 , 51} Stop Smoking in its Tracks (New South Wales); ⁵² Beyond the Big Smoke (Western Australia); ^{53 , 54} Be Our Ally Beat Smoking (Western Australia); ⁵⁵ Reducing Aboriginal Children’s Tobacco Exposure in the Pilbara; ⁵⁶ The Smokers Program (Maari Ma Health Aboriginal Corporation—New South Wales); ⁵⁷ No Smokes North Coast (New South Wales); ⁵⁸ the No More Boondah Program (ACT); ⁵⁹ Gippsland Tobacco Action & Healthy Lifestyle Team (Victoria); ⁶⁰ and tobacco control programs at Miwatj Health Aboriginal Corporation, ⁶¹ Kimberley Aboriginal Medical Services Corporation,  ^{6 2} the Tasmanian Aboriginal Corporation, ⁶³ and in remote north Queensland. ⁶⁴ This list is not exhaustive, and there are many other organisations working on tobacco action projects.

These projects include a selection of the following components:

• brief interventions
• specialised tobacco action workforce
• increased health care check-ups and subsequent referral advice
• training for the workforce (both specialised and general) in tobacco action, including in brief intervention
• pharmacological assistance—nicotine replacement therapies, bupropion, and varenicline
• hospital cessation programs
• referral to quitlines
• quit support groups
• health education activities—including education sessions, DVDs, websites
• social marketing campaigns, including television, radio, print, posters, pamphlets, the internet and mobile phones
• sponsorship of cultural, sporting and community events
• outreach-style programs, such as family-centred home-visit-based programs
• programs to reduce exposure to secondhand tobacco smoking in the home and/or car
• development and implementation of smokefree workplace policies
• programs to support specific sub-populations to quit—Aboriginal health workers, pregnant women, prison inmates
• prevention programs with youth and children
• incentive-based programs to encourage cessation
• broad state/territory and Commonwealth legislation.

Many of the multi-component tobacco action programs listed above have not been evaluated; others have been evaluated, but are not yet published. Published evaluations of multi-component projects in the Northern Territory ^{30 , 39 , 40} and North Queensland ⁶⁵ have found no measurable impact on smoking cessation, although one of the Northern Territory studies found increases in knowledge of the health effects of tobacco and readiness to quit. ⁴⁰ This and another Northern Territory study also found that those communities with the most tobacco action activity measured the greatest decline in tobacco consumption. ^{30 , 40} Importantly, the evaluation of the North Queensland Indigenous Tobacco Project found that health services and communities felt that they had minimal ownership and input into the project, and this may have affected the limited overall impact that the program had. ⁶⁵ The success of community-based multi-component programs relies on community ownership, and involvement in the development, implementation and evaluation of these programs. ¹

Other research has shown greater promise for multi-component programs. Evaluation of a complex, community-based tobacco control program implemented in eight remote north Queensland Aboriginal and Torres Strait Islander communities found that, despite considerable shortcomings in delivery of the various components, there was a significant decline in smoking and consumption. ⁶⁴ The Be Our Ally Beat Smoking (BOABS) study tested the effectiveness of a locally-tailored, intensive, multidimensional smoking cessation program provided by trained Aboriginal researchers. Twelve months after enrolment, the smoking cessation rate for participants in the program (n = 6), while not statistically significant (possibly due to the small sample size), it was double that of usual care. ⁵⁵ A project at the Maari Ma Health Aboriginal Corporation involved an intensive 12-week Smoker’s Program with a case manager and an individualised management plan (including nicotine replacement therapy and other pharmacotherapies, counselling support, referral to quitline and ongoing support) delivered in the context of other health service activities such as brief intervention training for all staff (even non-clinical staff), and the implementation of smokefree workplace policies. Within the context of these other activities, the Smoker’s Program appears to have been successful at promoting quit attempts among participants; 16.3% of Aboriginal people who had ever participated in the Smoker’s Program (up to June 2009) had a ‘quit’ status at 12 months after entering the program. ⁵⁷

8.10.3 Pharmacological assistance: nicotine replacement therapies, bupropion (Zyban) and varenicline (Champix)

There is evidence in other populations that nicotine replacement therapies (NRT), bupropion (Zyban) and varenicline (Champix) are effective at increasing the likelihood of cessation success (see Section 7.16). Since December 2008, nicotine patches have been available to Aboriginal and Torres Strait Islander patients at a subsidised cost on an authority script through the Pharmaceutical Benefits Scheme (PBS). ⁶⁶ Further, since July 2010 nicotine patches and other pharmacotherapies have become available to Aboriginal and Torres Strait Islander patients on an authority script for no cost to healthcare cardholders and at the concessional rate for others. This is available as part of the PBS co-payment measure of the Practice Incentives Program Indigenous Health Incentive to services that are accredited against the Royal Australian College of General Practitioners (RACGP) standards. ⁶⁷ Among those surveyed in 2012–13, the majority of Aboriginal and Torres Strait Islander peoples had obtained their last NRT free of cost. ⁶⁸ In 2014-2016, 10.8% of Aboriginal and Torres Strait Islander smokers received smoking cessation medicines through the Closing the Gap (CTP) PBS co-payment measure. NRT patches were the most dispensed cessation medicine through the CTP. ACT and NSW had the greatest rate of CTP prescriptions per smokers in the state, while NT had the lowest. Aboriginal and Torres Strait Islander smokers living in remote areas of the NT also accessed cessation medicine though the Remote Area Aboriginal Health Service program (RAAHS) which supplied 413 packs of NRT patches and 141 oral medicines (varenicline and bupropion) in 2016. ⁶⁹

However, some Aboriginal and Torres Strait Islander people will likely still face barriers to accessing health services that will hinder their ability to obtain NRT and other pharmacotherapies (such as cultural safety, language and racism). Other issues with the implementation of this incentive have also been raised, including the relatively lower rates of accreditation of Aboriginal community controlled health organisations; ⁷⁰ in 2010–11, while 71% of Aboriginal and Torres Strait Islander primary health-care services were accredited, 26% of these services had not achieved accreditation by the RACGP, ⁷¹ meaning they were ineligible for the incentive.  

In 2012–3, 37% of Aboriginal and Torres Strait Islander daily smokers in a national sample had ever used bupropion, varenicline or a NRT product and 37% had used them at in the past year. Nicotine patches were the most commonly used product among Aboriginal and Torres Strait Islander  smokers and recent-ex smokers (24%), followed by varencline (11%) and nicotine gum (10%). ⁷² Only a small number of studies have examined the effectiveness of nicotine replacement therapies and/or bupropion among Aboriginal and Torres Strait Islander peoples, and have found success rates between 6–19%—in New South Wales (two studies), ^{22 , 73} Queensland (one study), ⁶⁵ Northern Territory (one study) ³² and Victoria (one study). ⁷⁴ The sample sizes of most of these studies have been small, and none has been a randomised controlled trial. All have combined nicotine replacement therapy and/or bupropion with brief intervention and/or counselling or support. Although the quit rates are lower than those reported for other populations in the medical literature, ⁷⁵ these studies provide evidence that assisted availability of nicotine replacement therapy, in combination with appropriate cessation support counselling, could benefit some Aboriginal and Torres Strait Islander smokers. Several studies challenge the common perception that Aboriginal and Torres Strait Islander peopled tend to be heavy smokers, and suggest that nicotine replacement therapy prescription should not assume that Aboriginal and Torres Strait Islander smokers are necessarily heavily addicted. These studies have found low levels of nicotine addiction in some communities or sub-populations (measured by daily consumption based on store sales, ^76-78 or on the Fagerström Test for Nicotine Dependence ^{79 , 80} ) for whom nicotine replacement therapy prescription would not necessarily be appropriate.

Several studies have also surveyed Aboriginal and Torres Strait Islander peoples regarding their attitudes to and beliefs about pharmacological cessation assistance. In 2001, the National Aboriginal and Torres Strait Islander Tobacco Control Project found a high awareness of the existence of pharmacological aids to quitting smoking, and particularly of nicotine replacement therapy. However, a lack of factual information had led to a wide range of misconceptions and misunderstandings about the nature of these products and how they worked. ¹⁷ Similarly, a study in six remote Northern Territory communities reported that knowledge about how nicotine replacement therapy works was low. ⁵ Among the obstacles to access cited in these studies are: limited availability in some communities—nicotine replacement therapy is not routinely stocked, and there is a long delay between ordering and delivery of these medications; ⁵ health staff report a lack of knowledge and confidence in prescribing; ⁵ poor patient compliance—patients would not return for new supplies, or would run out after sharing their nicotine replacement therapy with other family members; ⁵ and cost. ^{5 , 17}

Activities that are likely to improve the success of nicotine replacement therapy in helping Aboriginal and Torres Strait Islander smokers to quit are: providing better information to patients and the community; ^{5 , 17} providing nicotine replacement therapy as part of a comprehensive tobacco cessation program; ¹⁷ providing ongoing support and counselling to patients through regular face-to-face meetings; ⁵ and providing nicotine replacement therapy free of charge to Aboriginal and Torres Strait Islander smokers wanting to quit. ^{5 , 17 , 81}

8.10.4 Telephone and internet support

8.10.4.1 Quitlines

Quitlines, when used as a component of anti-smoking campaigns, are cost effective and increase quit rates, particularly when multiple calls are made. ⁸² There is international evidence that quitlines can be acceptable to and effective for Indigenous peoples. ^83-86 An evaluation of Aboriginal and Torres Strait Islander utilisation of the South Australian Quitline in 2010 found that similar proportions of Aboriginal and Torres Strait Islander and non-Indigenous smokers registered for the service, and demographic variables and smoking addiction were also similar. However, Aboriginal and Torres Strait Islander callers received significantly fewer callbacks and were significantly less likely to set a quit date. Three months later, they were significantly less likely to have successfully quit. The authors suggest that tailoring the service might improve engagement. ⁸⁷ Other studies have shown that quitline services may be enhanced for Aboriginal and Torres Strait Islander peoples through cultural awareness and competency training of staff, ⁸³ the availability of Aboriginal and Torres Strait Islander quitline counsellors, ⁸⁴ the provision of nicotine replacement therapy in conjunction with telephone counselling, ^{83 , 84} and when broader anti-smoking campaigns are targeted to culturally specific groups. ⁸⁶ There is also need to increase rate of health professional referrals; in a 2012-3 national sample only 28% of Aboriginal and Torres Strait Islander smokers who are advised to quit are referred to Quitline. ⁸⁸  

One study in an Aboriginal health service in Victoria noted that, with encouragement, apprehension to receive support through quitlines was overcome, and that the quitline was well liked and potentially useful. ⁷⁴ Quitline have responded to many of these recommendations and the rate of utilisation is increasing. Over 2016-7 there was 12% increase in the number of calls to Quitline by Aboriginal and Torres Strait Islander smokers. ⁸⁹ However, quitlines are likely to be inappropriate and inaccessible for Indigenous people who live in remote or very remote areas, due to language barriers and access to the use of a phone. Improving access to and appropriateness of quitlines is one of the activities of the Tackling Indigenous Smoking programme, and includes enhancing access to Aboriginal and Torres Strait Islander-specific quitline counsellors (see Section 8.13.5). ⁹⁰

8.10.4.2 Internet and mobile phone interventions

The Internet and mobile phones offer enormous potential for the delivery of low cost and high reach cessation interventions, and a growing body of research supports their effectiveness in increasing quit rates, ^{91 , 92} particularly when they are tailored or interactive ⁹³ (see Section 7.14). The potential for using digital technologies in the production and distribution of tobacco cessation and prevention messages in Aboriginal and Torres Strait Islander communities is significant; videos and messages can be produced relatively inexpensively and distributed quickly and widely via social media websites and through mobile phone technology. The use and uptake of digital technologies by Aboriginal and Torres Strait Islander young people is increasing rapidly, including in remote communities, although many communities still experience issues with access to communication technologies and services. ⁹⁴ A study of the Facebook posts of Aboriginal Community Controlled Health Services (ACCHOs) found that smoking cessation and prevention posts had a greater engagement and reach when they came from sources outside of the service and when the message had First Nations specific content. Emotional appeal, post format (video or nonvideo) and communication technique showed no effect on the spread and engagement of smoking-related posts. ⁹⁵ In New Zealand, mobile phone messaging to disseminate smoking cessation messages and support appears to be acceptable to Māori people, including young people. ^{96 , 97} A study involving Māori and non-Māori found that using mobile phones to communicate smoking cessation messages resulted in an increase in short-term self-reported quit rates, and was equally successful with Māori as with non-Māori. ⁹⁷

A 2014 review found that despite the considerable potential of social media and mobile phone interventions, current evidence for their effectiveness or health benefit among Aboriginal and Torres Strait Islander peoples is sparse and mixed. The most robust evidence is in international studies exploring text messaging for smoking cessation, but a more comprehensive understanding of their role in quitting among Aboriginal and Torres Strait Islander Australians is needed. ⁹⁸ The authors summarise the apps and social media programs as follows:

8.10.5 Support groups

While individually based interventions may work best for some, research also highlights the possible advantages of establishing support groups for those who want to quit smoking, particularly older smokers who find it difficult to resist the smoking behaviour of their peer group. These groups, preferably led by an Aboriginal and Torres Strait Islander ex-smoker and perhaps open only to Aboriginal and Torres Strait Islander peoples, would build upon sense of community and be likely to increase the success of quit attempts. ^{26 , 81} The concept of rehabilitation-style programs, like those offered for alcohol and other drug withdrawal, has also been raised as a possibility. ¹⁷

There has been limited evaluation of quit support group programs for Aboriginal and Torres Strait Islander peoples, though a small number of studies point to the potential of quit groups delivered as part of a more comprehensive approach and when modified to meet the needs of Aboriginal and Torres Strait Islander communities. A short course delivered in group sessions over a three-week period by an Aboriginal medical service in a rural community in Victoria achieved a 19% quit rate (6 of 32 participants). However the course was part of a multi-component community intervention that included brief cessation advice, nicotine replacement therapy, ongoing support from Quitline and the quit facilitator and an individually tailored management plan that involved a range of health professionals. ⁷⁴ Similarly, the ‘No More Boondah’ program in the ACT includes group support sessions as part of comprehensive smoking cessation supports. An unpublished evaluation shows that it has been successful at engaging community members, and supporting them to quit. Of the program participants, 29.8% ceased smoking and a further 23.9% reduced their smoking, an effect that remained at two and six months follow up. ⁹⁹

An evaluation in NSW of ‘Give up the Smokes’—a culturally-appropriate group smoking cessation program for Aboriginal and Torres Strait Islander peoples—reported a 30% quit rate after three months, which is comparable to cessation outcomes in non-Indigenous populations. ¹⁰⁰ A study in remote North Queensland offered assistance to local councils to implement the ‘Smoke Rings’ group support program for Aboriginal and Torres Strait Islander smokers; however, only one of five councils adopted the program. This study highlighted significant problems with program implementation in remote communities, with no local health workers available to assist with delivering the program, one in five participants being a non-smoker, and poor and decreasing engagement. Smoke Rings formed part of a comprehensive suite of interventions, which together led to a reduction in smoking. ⁶⁴

Health and welfare staff (n=19) working in remote Northern Territory communities reported that programs that are unmodified from the mainstream content and delivery mode are inappropriate for this setting. The course and materials should not only be translated appropriately, but the concepts in the program need to be ‘translated’ into an Aboriginal and Torres Strait Islander worldview. In one community, staff had adjusted the group program to be delivered informally to family groups within their homes, rather than to mixed groups at a central location. ⁵

8.10.6 Specific groups

See Section 8.3 for the prevalence of smoking among these groups.

8.10.6.1 Aboriginal health workers

A number of multi-component projects have been developed specifically to support Aboriginal health workers to quit smoking. These projects generally include a range of activities, such as providing free nicotine replacement therapy, support groups, intensive follow-up, support for families of Aboriginal health workers to quit alongside them, incentives for staff to quit, and smokefree workplace policies. ^{53 , 101} Research in South Australia recommends an ecological approach to support smoking cessation among Indigenous health workers, incorporating both individual level strategies and addressing social determinants of smoking. ¹⁰²

8.10.6.2 Young people

Reviews of mainstream studies have found that there is limited evidence for the effectiveness of school-based programs for smoking prevention among young people when the programs are based on information giving or developing general social competence, ¹⁰³ but that co-ordinated, widespread, multi-component community interventions are effective. ¹⁰⁴ Mass media campaigns may also be effective for young people when well researched and appropriately developed and delivered. ¹⁰⁵ For example, the No Smokes campaign found hard-hitting and personally relevant anti-tobacco messages were most likely to be recalled by youth. In addition, knowledge about tobacco’s adverse effects was most effectively increased by factual videos and repetitive messages, while humorous videos were the least effective. ¹⁰⁶

Social media marketing is also increasingly common in youth programs given it is used more by Aboriginal and Torres Strait Islander youth than traditional medias, though there is limited quality evidence for its effectiveness. ^{107 , 108} A study of the Deadly N Ready and Buttout Kids About social media campaigns found 32 % of respondents said the campaigns had prompted them to talk to a family member or friend about smoking and 27% said it had led them to speak to their doctor. ⁸⁹

Smoking prevention programs aimed at children are recognised as a priority area for action by many Aboriginal and Torres Strait Islander people. ^{17 , 25 , 81} Respondents to the National Aboriginal and Torres Strait Islander Tobacco Control Project Survey felt that schools-based programs must begin in the early primary years, and should be reinforced at every year level, at every opportunity. Appropriate and appealing resources using visual, interactive, and memorable elements (such as jingles and songs) were thought to be helpful. It was also considered important to provide adequate recreational facilities and organised activities to support children through the hours when they are not at school, when key factors contributing to uptake—such as peer group pressure, concerns for personal image, and boredom—may be at their height. ¹⁷

However, as suggested by the evidence from the mainstream context, school-based programs alone are clearly not sufficient to address smoking uptake by young people. Particularly in communities where school attendance is sporadic, other means of conveying messages to children need to be found. ¹⁰⁹ The importance of family influence on smoking behaviours highlights the potential of family- and community-based interventions, which target both adults and children to impact the rates of uptake among youth. ^{25 , 110 , 111} Reducing the social acceptability of smoking in Aboriginal and Torres Strait Islander communities, and reducing smoking among significant adults who are likely to influence young people to take up smoking, should arguably receive a greater emphasis in these programs. Aboriginal and Torres Strait Islander participants in an evaluation of the National Tobacco Campaign felt that the emphasis of tobacco control programs should be on older smokers, as they felt that smoking was highest in this group, that many were suffering from smoking-related illnesses, and that they would be most likely to influence other community members, including young people, to quit. ²⁶

While there have been several tobacco action initiatives that target Aboriginal and Torres Strait Islander young people, none have been evaluated for their impact on smoking uptake. Some of these programs have been school based, ^{109 , 112} while others have been community based, ¹¹³ or part of multi-component programs. ^{45 , 50 , 61 , 65 , 114 , 115} As part of a comprehensive tobacco control program in remote areas of Queensland, 10 teachers across three schools (two primary and one secondary) were trained in the Smokin’ No Way program. At evaluation, none used it as intended (as a set of structured lesson plans), though seven teachers reported using some components with positive responses from students. No schools developed systems to continue use of the resource, and although it was occasionally used up to 10 months after the project, teachers thought it was unlikely that it would still be in use the following year. High turnover of teachers was suggested as a hurdle to continued use, and annual training was suggested to improve sustainability. ⁶⁴ An analysis of Victorian data from the Australian Secondary Students’ Alcohol and Drug Survey shows an association between intensive anti-tobacco campaigns and reduced prevalence of smoking among Aboriginal and Torres Strait Islander (and non-Indigenous) school students. ¹¹⁶

8.10.6.3 Pregnant women

Smoking during pregnancy is the most common preventable risk factor for pregnancy complications (see Section 3.7 and Section 7.1.4). Most published studies of smoking in Aboriginal and Torres Strait Islander pregnant women are descriptive studies (see sections 8.3.3, 8.6.6.1 and 8.7.4). There are several projects that have focused specifically on providing training and resources; for example, the Indigenous Women’s Project through the Asthma Foundation Western Australia; ¹¹⁷ the Smoke-free Pregnancy Project—Aboriginal Women and their Families through Quit South Australia; ¹¹⁸ and the For Me & Bub SmokeCheck Pregnancy Project in Queensland. Pilot data from a randomised controlled trial investigating the effectiveness of a high-intensity intervention with pregnant women at three Aboriginal and Torres Strait Islander health services in Queensland and Western Australia found no difference in smoking cessation rates between the control and intervention groups; however, the rate of smoking cessation achieved overall was 11%. ¹¹⁹ Findings from the main study showed that there were again no significant differences in smoking rates between the two groups at 36 weeks. Of the women followed up, 89% in the intervention group and 95% in the usual care group were smokers. However, the authors note significant methodological limitations, which may have affected results. ¹²⁰

A multi-component program, Goreen Narrkwarren Ngrn-toura (Healthy Family Air), was developed and evaluated in Victoria. This project involved a three-pronged approach of training health staff, improving organisational capacity and integrated support within health services, and community development. ^{15 , 51} A literature review produced for this project suggested the integration of services for pregnant women into existing clinical practice, incorporating tobacco action activities into routine antenatal care practices. It also suggested a multi-component program, including tobacco action activities targeting the family and community such that a more supportive environment for quitting is created for the pregnant woman. ¹⁵ The project was broadened to include the whole community because of the many influences that the family and community have on pregnant women. ⁵¹ Post-implementation findings suggested that social marketing techniques are helpful for overcoming local and site-specific barriers to smokefree policy implementation, and that it is important to frame messages in terms of community and family responsibility. Provision of smoking cessation counselling and products strengthened smoking cessation messages and smokefree policies. The authors recommend that training for health professionals be strengthened by including smoking cessation experiences of Aboriginal people, and access to brief intervention and quit facilitator training should be increased for staff at Aboriginal Community Controlled Health Organisations. ¹²¹ A health professional training program, Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy, was developed in conjunction with Aboriginal Medical Services (AMSs), Aboriginal and Torres Strait Islander women and communities. The program provided training for GPs, AHWs and midwives in culturally responsive brief interventions and the use of NRT for pregnant Aboriginal and Torres Strait Islander women in addition to free oral NRT for pregnant Indigenous women. ¹²² The pilot study found that health professionals knowledge of and attitudes to smoking cessation care improved after the training, though their self-reported practices such as NRT prescription were unchanged. ¹²³    

A further component of programs with pregnant Aboriginal and Torres Strait Islander women that is yet to be evaluated is the use of incentives. A systematic review and meta-analysis of research on the role of personal financial incentives in promoting healthy behaviours found that they increased smoking cessation, which was the only habitual health-related behaviour (compared with eating, alcohol consumption and physical activity) for which changes were maintained up to 18 months from intervention start and sustained after incentive removal. ¹²⁴ Several programs in other countries have shown success with using incentives to assist pregnant women to quit smoking. ^{125 , 126} A review of smoking interventions with pregnant women found that the most successful intervention appeared to be the use of incentives. ¹²⁷ Another review has suggested that the use of incentives is likely to be improved by the value, the immediacy to the positive behaviour, the periodic (as opposed to one-off) delivery of the reward, rewarding support from the individual’s social network, and being part of a broader program that also builds skills and confidence. ¹²⁸ Research in a highly deprived area of England found that offering financial incentives that increased in value with duration of abstinence led to quit rates of 20% at delivery and 10% at 6 months postpartum. ¹²⁹

The use of incentives may be a successful approach in Aboriginal and Torres Strait Islander communities, although their use is not universally supported. A roundtable of researchers and health professionals, including Aboriginal and Torres Strait Islander health workers, were generally cautious about the use of incentives and were not enthusiastic about their use in smoking cessation programs for pregnant Aboriginal and Torres Strait Islander women. ¹³⁰ However, a NSW study involving Aboriginal and Torres Strait Islander pregnant women and health workers found good support for the use of ‘rewards for women who stop smoking with vouchers to get things for the mother or baby’: 63% among the pregnant women who smoked; and 56% among the workers. ¹³¹ A program related to this study aimed to help pregnant Aboriginal women in rural New South Wales to quit smoking by delivering an incentives-based program offering rewards in gradually increasing amounts until six months postpartum. These rewards were offered within a comprehensive program that also included counselling, provision of specifically designed resources, free nicotine replacement therapy for the women and those in their households, quit support groups and household resources. Of the nineteen women completing the program, sixteen made a quit attempt, and eight remained confirmed non-smokers in late pregnancy. ⁵²

More generally, a 2013 systematic review of research on cessation support for pregnant Aboriginal and Torres Strait Islander women found that there was no evidence for any interventions that are effective. This hinders development and implementation of evidence-based policy and practice. ¹³² A study exploring views of pregnant Aboriginal and Torres Strait Islander women and their antenatal care providers on strategies to support smoking cessation found that smokers were less positive about the potential effectiveness of most strategies than the providers. For example, family support was considered helpful by about two thirds of smokers and almost all providers; proportions were similar regarding the helpfulness of advice and support from health professionals. Rewards for quitting were considered helpful by about three in five smokers and providers, with smokers rating them more highly and providers rating them lower, than most other strategies. Quitline was least popular for both. ¹³¹ Research in 2015 found that although most pregnant Aboriginal and Torres Strait Islander women reported receiving advice and support to quit, the persisting high prevalence of smoking suggests that this support is insufficient to overcome the many factors that promote smoking amongst this group. ¹³³  Increasing knowledge about antenatal smoking risks may motivate some women to try to quit; however, this alone is unlikely to address the many interacting factors that lead to and perpetuate smoking. Addressing the social environment and daily stressors, particularly those exacerbated by pregnancy, may be critical to supporting quit attempts. ¹³⁴ A qualitative research study published in 2020 investigated which features were most valued in an Aboriginal and Torres Strait Islander pregnancy cessation program, and identified holistic approach, relationship-basis, cultural orientation, individualisation and flexibility. ¹³⁵

8.10.6.4 People experiencing incarceration

Traditionally, there have been very high rates of smoking by Aboriginal and Torres Strait Islander peoples experiencing incarceration (see Section 8.3.5) along with significant challenges to providing tobacco control activities within prisons. ¹³⁶ Tobacco is a commodity that plays an important social role within prisons, and there is considerable debate over the practical and moral issues around the management of smoking within prisons, including making prisons, or even parts of prisons, smokefree. ¹³⁷ Nonetheless, all Australian states and territories except Western Australian have introduced or are planning to introduce complete smoking bans in prisons. 

In the absence of total bans, smoking cessation programs should take into account the unique stresses of the prison environment. ¹³⁸ Programs should also be ongoing to accommodate the constantly changing prison population, and the changes in the readiness to quit of individual prisoners. ¹³⁷ Smoking cessation programs have been implemented within some prisons, ¹³⁶ with some specifically targeting Indigenous prisoners, ^{14 , 139} but there has been little evaluation of these programs for their impact on smoking cessation. One study that evaluated a program in a New South Wales prison prior to the state-wide ban—where participants (n=30, with 50% Aboriginal) were offered a combination of bupropion, nicotine replacement therapy, brief cognitive behavioural therapy and self-help resources—found a quit rate of 26% at six months, with the rest of the participants reporting that they smoked less tobacco per week. ¹⁴⁰