8.10 Tobacco action initiatives targeting Aboriginal peoples and Torres Straits Islanders

Although health practitioners, community members and researchers have been working for many years to reduce tobacco use in Aboriginal and Torres Strait Islander communities, the delivery of tobacco action programs in these communities has until recently typically been marked by a lack of coordination and limited resources. ^1–8   In 2008, the Tackling Indigenous Smoking Initiative was announced, which represented a significant commitment to a strategic approach to Indigenous tobacco action with accompanying funding; however, the 2014 budget saw the program’s funding cut by $130 million over five years—more than a third of the annual funding. ⁹   The redesigned Tackling Indigenous Smoking program has a budget of $116.8 million over three years until 2018  (see  Section 8.13.5 ).

To date, critical evaluations of the various 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 tobacco (health promotion) initiatives aimed at reducing 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. ^1,8,10–12   A systematic review of trends in Indigenous Australian tobacco research from 2004 to 2013 found that, despite a surge in research output in 2008 relating to Indigenous tobacco control, there are still few intervention studies available to guide efforts to reduce tobacco-related health disparities. ¹³   Rigorous evaluations, particularly of secondary prevention programs and comprehensive community-wide programs, are needed to build the evidence base around tobacco action initiatives in Aboriginal and Torres Strait Islander communities. ¹⁴  

Despite the limited evidence about what works in Indigenous tobacco control, ^14.15  several reviews have identified the likely factors critical to the success of designing appropriate tobacco initiatives for Aboriginal and Torres Strait Islander communities. ^{1–8,10,11,15–17}   Important principles that should underpin tobacco action in Aboriginal and Torres Strait Islander communities to enhance program delivery include: ^{5,6,8,10,18–20}      

• maximising community control, and building capacity within Indigenous 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 Indigenous 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 people. 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. ²¹   

This section will summarise the current evidence around successful tobacco action interventions in the Australian Indigenous context, and provide examples of programs and activities that have been (and are being) implemented in Aboriginal and Torres Strait Islander communities. 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

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 Indigenous 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. ¹²  In addition, there are many nations within Australian Aboriginal 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 Indigenous 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. ²²  

These socio-economic factors also contribute to the complex stressors that Aboriginal peoples and Torres Strait Islanders may face in their daily lives. Smoking is commonly perceived as a means of coping with stress  (see  Section 8.9.1.1 ). ²³   However, smoking appears to increase stress levels, ²⁴  while quitting is associated with reduced stress, depression, and anxiety; ²⁵   therefore, an additional benefit of cessation may be improving the mental health of Indigenous 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 among Indigenous peoples, 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%. ²²   Clearly, social and cultural factors also play a role in promoting smoking ²⁶   (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 Indigenous communities. ²⁶   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. ²⁷  

Some argue that mainstream public health messages lack relevance for many Indigenous people. ^12,27,28  Several studies suggest, however, that many mainstream tobacco action activities are acceptable to and effective for Aboriginal peoples and Torres Strait Islanders  (see  Section 8.10.11 ). ^12,29,30  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. ¹²  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 Indigenous people  (see  Sections 8.10.4  and  8.10.5 ). Adequate and sustained funding to the healthcare system specifically for Indigenous people and specifically directed towards tobacco action has also been cited as necessary for program success. ^5,8,31   

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. ³²  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. ³²  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 Indigenous smokers quitting by themselves; some studies have noted high levels of Indigenous smokers who have quit without the use of organised programs or specific help. ^33,34  

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. As with other disadvantaged groups, 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. ³⁵  Equally, effective tobacco control strategies that reduce uptake and promote cessation can help address many of these problems, for example by improving mental health ²⁵  and relieving financial stress. ³⁶  

Such multi-level, comprehensive approaches are consistent with the principles of Indigenous 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’, ³⁷  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. ³⁸  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. ³⁹  

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; ^40,41  the Top End Tobacco Project (Northern Territory); ^42,44,45  Clean Air Dreaming (New South Wales); ⁴⁶  Building Research Evidence to address Aboriginal Tobacco Habits Effectively (BREATHE), ⁴⁷  and Tobacco Resistance and Control (A-TRAC) Program (Aboriginal Health and Medical Research Council of New South Wales); ⁴⁸  Our Space Smoke Free (Queensland); ⁴⁹  Deadly Nungas Say No to Puiya (South Australia); ^50,51  Northern Territory Tobacco Project; ³¹  Goreen Narrkwarren Ngrn-toura (Healthy Family Air) (Victoria); ^7,52  Stop Smoking in its Tracks (New South Wales); ⁵³  Beyond the Big Smoke (Western Australia); ^54,55  Be Our Ally Beat Smoking (Western Australia); ⁵⁶  Reducing Aboriginal Children’s Tobacco Exposure in the Pilbara; ⁵⁷  The Smokers Program (Maari Ma Health Aboriginal Corporation—New South Wales); ⁵⁸  No Smokes North Coast (New South Wales); ⁵⁹  the No More Boondah Program (ACT); ⁶⁰  Gippsland Tobacco Action & Healthy Lifestyle Team (Victoria); ⁶¹  and tobacco control programs at Miwatj Health Aboriginal Corporation, ⁶²  Kimberley Aboriginal Medical Services Corporation,  the Tasmanian Aboriginal Corporation, ⁶⁴  and in remote north Queensland. ⁶⁵  This list is not exhaustive, and there are many other organisations working on tobacco action projects (see footnote i).

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 ^31,40,41  and North Queensland ⁶⁶  have found no measureable 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. ⁴¹  This and another Northern Territory study also found that those communities with the most tobacco action activity measured the greatest decline in tobacco consumption. ^31,41  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. ⁶⁶  The success of community-based multi-component programs relies on community ownership, and involvement in the development, implementation and evaluation of these programs. ⁸  

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 Indigenous communities found that, despite considerable shortcomings in delivery of the various components, there was a significant decline in smoking and consumption. ⁶⁵  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. ⁵⁶  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. ⁵⁸  

8.10.3 Harm reduction approaches

Roche and Ober have argued that adoption of harm reduction strategies might usefully increase the range of initiatives open to health workers in Aboriginal and Torres Strait Islander communities. ⁶⁷  Harm reduction places a priority on limiting damage caused by tobacco use, rather than making cessation the primary goal. In societies where tobacco use is endemic and barriers to quitting complex, it may be that the pragmatic approach offered by harm reduction is more likely to deliver measurable health benefits. Cutting down on the number of cigarettes has been reported by Indigenous smokers, particularly in studies of pregnant smokers, as a conscious strategy to reduce tobacco-related harm; ^63,68  however, this approach is not recommended by peak public health organisations, ^69,70  as the long-term health benefits of a reduction in smoking is unclear. ⁷¹  Cutting down, particularly when combined with nicotine replacement therapy, appears to be more useful as a step toward quitting. ⁷¹

Elements of harm reduction in relation to tobacco use might include increasing ease of access to treatment, protecting non-smokers (e.g. by introducing smokefree areas), and monitoring for early signs of smoking-related illness. ⁶⁷  Roche and Ober contend that given the damage tobacco causes among Aboriginal and Torres Strait Islander communities, it is likely that any potential gains accrued from adoption of a harm minimisation approach would outweigh possible disadvantages. However, they underline the need for monitoring and evaluation of any strategies, particularly the importance of allowing particular communities to develop their own programs. 

8.10.4 Roles of health services

Smoking cessation activities are available to Aboriginal peoples and Torres Strait Islanders through a variety of health service contexts: Aboriginal community controlled health services, pharmacies, and general practitioners. Recent developments in Aboriginal health policy and funding have been strategically directed within these sectors to address chronic diseases and risk factors such as smoking. ^72,73   

Many Indigenous people access healthcare primarily through Aboriginal community controlled health services. These organisations are largely governed and managed by Indigenous people from the local community, and employ Aboriginal health workers to assist in the delivery of holistic, comprehensive, and culturally relevant healthcare. Aboriginal community controlled health services have an important role to play in implementing smoking cessation activities, but the nature of these activities, and their capacities to deliver them, vary from location to location. Smoking cessation programs may include: clinical level activities such as brief interventions, nicotine replacement therapy provision and support programs; and preventive activities within the health services, such as health education, social marketing, and the development of supportive workplace policies. Staff from Aboriginal community controlled health services may also become involved with supporting broader community-level initiatives, such as developing local social marketing campaigns, policies around smokefree community areas, or programs delivered through schools, stores or other organisations. Many health services are also specifically implementing programs and activities to support their staff to quit smoking  (see  Section 8.10.13.1 ).

A number of studies have documented the service capacity issues faced in delivering tobacco control programs within Aboriginal community controlled health services. ^{12,31,35,63,74}    Traditionally, many health services have found it difficult to prioritise tobacco control as there are so many other competing and immediate health and social issues; service delivery have often placed a disproportionate focus on acute biomedical healthcare rather than on preventive healthcare. ^12,35,74  Some health workers report that there is not enough time to build relationships with patients that are sufficiently robust to enable them to raise what they see as sensitive and confronting lifestyle issues (such as smoking). ⁷⁴     Health service staff involved in one study suggested adult health checks as an enabler to conducting brief interventions, but several services in this study had found it difficult to incorporate adult health checks into their work practice. ⁷⁴     Other service capacity issues include: the capacity (particularly time and resources) to provide and support adequate training; ^12,74  high staff turnover and difficulty retaining skilled staff; ^31,35,74  inadequate resourcing to sustain activities; ³¹  lack of infrastructure to adequately provide programs; ⁷⁴  and lack of follow-up services to which to refer patients. ⁶³     

Taking a team approach to healthcare delivery, ¹²     and strong and consistent leadership ⁷⁴  have been recognised as enablers to implanting cessation interventions. One study found that where the community is ‘ready’ to respond to smoking—i.e. tobacco control has been identified as a priority, key stakeholders are mobilised, and staff have been made available to implement activities—tobacco control activity is more likely to occur. ³¹  Indeed, national 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 this translated to smokefree policies, staff training in tobacco control, extra smoking cessation support for staff, and the provision of a range of quit-smoking information and activities for clients and the community. ⁷⁵     

While Aboriginal community controlled health services are central in the delivery of healthcare to Aboriginal peoples and Torres Strait Islanders, many Indigenous people will access mainstream services—i.e. those without Indigenous structures of governance. The effectiveness of such services may be limited by factors such as cost, reduced cultural safety, language barriers, and racism (whether perceived or actual). It is crucial that mainstream services are well equipped, through appropriate training, funding, and referral relationships, to work with Aboriginal and Torres Strait Islander clients. For example, the Practice Incentives Programs Indigenous Health Incentive provides financial incentives for general practices to manage complex chronic disease issues for Indigenous patients, and the Pharmaceutical Benefits Scheme Co-payment Measure enables the subsidisation of  medications (including nicotine replacement therapy and other pharmacotherapies) for the prevention or management of chronic diseases. ⁷⁶  Hospitals can also provide support to Indigenous inpatients who have been identified as smokers, for instance by informing them of the hospital’s smokefree policy, advising and supporting them with options for managing nicotine withdrawal during their stay, and offering them further support after discharge. ⁷⁷   High-intensity cessation support has been found to result in higher quit rates in other populations, ⁷⁸  and could also be successful for Aboriginal peoples and Torres Strait Islanders. ¹

Smoking cessation activities are available to Aboriginal peoples and Torres Strait Islanders through a variety of health service contexts: Aboriginal community controlled health services, pharmacies, and general practitioners in community or government health services and private practice. Recent developments in Aboriginal health policy and funding have been strategically directed within these sectors to address chronic diseases and risk factors such as smoking. ^60,61

8.10.5 Roles of Aboriginal health workers

Aboriginal health workers are critical to the delivery of primary healthcare interventions and therefore play an important role in addressing smoking in communities. However, they face very particular challenges in delivering tobacco action activities. Such workers often come from and reside in the communities where they work. ⁷⁹  Since they are part of the same social context as their client base, it is not surprising that they also have comparatively high smoking rates  (see  Section 8.3.4 ). The nature of the work and the workload is also stressful, given that they are immersed in communities with high health and welfare needs, operate within time and resources constraints, and have specific social expectations placed upon them by family and community members. ⁸⁰  The stress and grief that accompanies their work makes it more difficult for Aboriginal health workers who smoke to quit themselves, ⁸¹  and also provides a challenging work environment within which to deliver smoking cessation activities. 

Studies report varying rates of Aboriginal health workers asking clients about their smoking status and talking to clients about cessation. One Western Australian study of 36 Aboriginal health workers reported that one-third asked all of their clients if they smoked, but just over a quarter asked none. ⁸²  In a New South Wales study involving 98 Aboriginal health workers, 80% reported providing quit smoking advice in their professional capacity. ⁸³  However, while most Aboriginal health workers in a qualitative study in Western Australia (n=10) reported routinely asking their pregnant clients if they smoked, very few followed this up with specific cessation advice. ⁶³  Another study with Indigenous pregnant women found that while most had been asked by a health worker during their antenatal care if they smoked (95%), fewer had been given advice to stop smoking (83%), and even fewer had been offered support to stop smoking (65%). ⁸⁴  The National Aboriginal and Torres Strait Islander Tobacco Control Project also found that fewer than half of surveyed health staff reported that they had discussed tobacco with clients. ¹⁸  More recently, among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers surveyed in 2012–13, almost all daily smokers who had seen a health professional in the year prior recalled being asked if they smoke, and three quarters were advised to quit. This advice was associated with making a quit attempt. ⁸⁵   

Aboriginal health workers may face a range of barriers that hinders their capacities to provide smoking cessation advice, which include high prevalence rates, community attitudes to smoking, and their levels of confidence, knowledge and skills to deliver tobacco control activities. The lower relative priority of smoking when compared to other more urgent health and social issues affecting clients’ lives (including from other more immediately damaging alcohol and drug misuse) affects the extent to which health workers prioritise smoking cessation in the clinical context, and their capacity to undertake preventive activities in tobacco control. ^35,63,83  Looking from the perspective of the client rather than the health worker, The Forgotten Smokers reported that smokers felt they had limited access to health workers, and that health workers were generally too busy caring for people with acute health problems to have the time to talk about smoking. ⁸⁶  The need for a specialised tobacco action workforce is widely recognised as a way to improve the capacity of services to deliver tobacco action activities, ^5,12,87  and forms the backbone of the response under the Tackling Indigenous Smoking program. ⁷³  

There is a consistent view across various geographical settings that high rates of smoking among Aboriginal health workers may affect their confidence and capacity to offer smoking cessation advice to their clients. ^{27,35,79,82,83,88}  A small Western Australian study reported that compared with Aboriginal health workers who smoke, those who are non-smokers and ex-smokers are more likely to advise smokers to quit and to provide warnings about the detrimental health effects of smoking. ⁸²  Similarly, a national survey of staff of Aboriginal community-controlled health services found that ex-smokers were most likely to report being confident in talking to others about smoking and quitting. ⁸⁹   

Health workers who smoke may feel hypocritical or as though they lack credibility when providing cessation advice, particularly if they have unsuccessfully attempted to quit. ^27,88  Aboriginal health workers have reported that if they could quit themselves, they would feel more confident speaking to community members about quitting. ⁸⁸  They have also expressed desire for support in the workplace to quit, such as nicotine replacement therapy, quit groups and quit buddies. ⁸⁸  However, research from New South Wales has shown that some health workers who were non-smokers also felt uncomfortable discussing smoking, since they lacked personal experience of tobacco addiction and making quit attempts. ⁸³  Another study in Western Australia reported that two non-smoking Aboriginal health workers (of 36 total participants) felt uncomfortable talking to clients about cessation as they worked with colleagues who smoked and so did not want to appear hypocritical by association. ⁸²   

Aboriginal health workers (whether smokers or non-smokers) have also expressed concern that discussing smoking cessation could be perceived by their clients as judgemental and moralising. ^35,63,82,90  Health workers have reported being concerned about making their clients feel badly about themselves by raising smoking cessation, particularly when so many other health and social issues are affecting them. ^35,63  Some Aboriginal health workers have reported discomfort at providing smoking cessation advice to elders or respected family members, ^12,35,82,91  and some are also worried that raising smoking will damage the therapeutic relationship and discourage patients from returning for ongoing healthcare. ^63,74  They have reported attenuating this discomfort by using less confrontational strategies for talking to people about smoking, including speaking about the general effects or talking about reducing passive smoking around children. ⁶³  However, while Aboriginal health workers have these concerns, their clients do not necessarily agree. One study with pregnant Indigenous women in New South Wales found that 80% of the women thought that healthcare workers should advise pregnant women to quit. ⁸⁴  There is also strong support among Aboriginal communities for smokefree Aboriginal community-controlled health services, with national surveys showing that 87% of non-smokers, 85% of ex-smokers, and 77% of daily smokers support a complete ban on smoking inside and around the buildings. ⁷⁵  

Studies and workshops examining workforce issues in Indigenous tobacco control cite lack of knowledge, skills and training as other reasons for not providing information to promote quitting. ^{14,18,35,50,82,83,86,90,92–95}  While smoking is part of the competencies in Aboriginal health worker training, how this is actually taught varies from provider to provider. A survey of training providers found that most taught general information about tobacco use, but few provided skills-based training in facilitating quit groups or in using nicotine replacement therapy. Additional resources were needed for both Aboriginal health workers and the trainers. ⁹⁴  Another study supports this finding that training should cover more than simply brief interventions, and include information about addiction, motivational interviewing and the use of pharmacotherapies. ⁸²  Indigenous-specific packages to deliver brief intervention training have been developed (see  Section 8.10.6), and other training packages and toolkits have been developed around the country. ^95,96

8.10.6 Brief interventions and brief intervention training

Brief interventions delivered by health professionals are effective in reducing smoking prevalence in various mainstream settings, ^97–99  and are quick, inexpensive and non-invasive to deliver. ⁸  There have been no studies specifically evaluating the efficacy of brief interventions delivered to Aboriginal peoples and Torres Strait Islanders, particularly when delivered by Aboriginal health workers. A number of evaluations have included brief interventions or individual counselling as part of the overall delivery of treatment, ^33,66  but it is difficult to assess the contribution of brief interventions to cessation rates. A qualitative study involving interviews with 25 residents of remote Northern Territory communities reported that for those with a smoking history (15 current smokers, six ex-smokers, two recently quit smokers) brief interventions from Aboriginal health workers were influential in their decision to quit, particularly when provided in the context of acute health events. ¹²  

In mainstream settings, training health professionals in providing smoking brief interventions has been shown to have a measurable effect on their professional practice; they are more likely to identify smokers and to provide them with smoking cessation advice than untrained professionals. ¹⁰⁰   Even when doctors merely provide brief, simple advice about quitting, this increases the likelihood a smoker will successfully quit and remain a non-smoker 12 months later. ¹⁰¹  

In Indigenous contexts, training programs such as SmokeCheck have been rolled out in several states to address the lack of skills and confidence that health workers face in delivering smoking cessation advice and tobacco programs. SmokeCheck has been adopted in Queensland, New South Wales, South Australia and Western Australia, and evaluated in Queensland and New South Wales. ^90,102  The evaluation of the New South Wales SmokeCheck program found that there were significant increases in the confidence of health workers to talk to their clients about the health effects of smoking, raise ‘quitting’ with clients making health visits for unrelated reasons, assess clients’ stage of change for smoking cessation/readiness to quit, and raise smoking as a point of discussion with clients. In addition, there were increases in the number of health workers who provided advice about nicotine replacement therapy, secondhand tobacco smoke, and cutting down tobacco use. More Aboriginal health workers recognised the importance of offering smoking cessation advice to their clients after the training, and perceived that it was easier to offer this advice after having received the training. The number of Aboriginal health workers living in smokefree homes increased during the project, as did the availability of culturally appropriate written resources to support clients to quit. ¹⁰²  Similarly, evaluations of the use of SmokeCheck in Queensland ^35,66,90  and New South Wales ¹⁰³  found that health workers were satisfied with the training, that it increased their confidence to deliver smoking cessation advice appropriately, and that it improved their clinical practice. However, one study found that six months after their training, most health workers failed to deliver the intervention as intended due to perceived challenges in working in remote Indigenous communities. ³⁵  Similarly, follow up interviews with health workers trained in SmokeCheck in remote North Queensland indicated that while they felt positive about the training, they did not use brief interventions in the manner in which they had been trained, reporting instead that they adapted and used only some of the components. ⁶⁵  

While SmokeCheck training may have benefits for practitioners who smoke, its effectiveness in improving smoking cessation rates for patients is not yet clear. One study of the South Australian SmokeCheck program that has followed up clients at three and six months appears to have encouraged quit attempts, but the numbers are too small to make definitive statements about the success of this program. ¹⁰⁴  In a study evaluating the impact of a SmokeCheck pilot program in Queensland, there was no evidence that any patients or practitioners had given up smoking after six months. ³⁵  The remote North Queensland research mentioned above implemented SmokeCheck (albeit inconsistently) as part of a comprehensive tobacco control program, which overall resulted in a decline in consumption among Indigenous communities. ⁶⁵    

Quit Victoria has also been involved in developing and delivering educator training to Indigenous communities in Victoria and the Northern Territory. This two-day training program provides general information and brief intervention training, and notably presents this in an interactive way to promote participants to think about and problem solve the challenging situations in which they may find themselves. ⁹¹  Quit South Australia is funded by the Commonwealth government as part of the Tackling Indigenous Smoking program to provide a number of different smoking cessation training courses (Quitskills and Motivational Interviewing) to health workers who work with Aboriginal peoples and Torres Strait Islanders. ¹⁰⁵  While these programs may be successful in improving health worker confidence to talk to clients about smoking cessation, the impacts on actual smoking rates, as with the SmokeCheck program, are not known.

8.10.7 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 Chapter 7). ^106–108  A review of studies in the US found that nicotine patches or bupropion were effective at helping African American smokers to quit, ¹⁰⁹  and a study involving Maori smokers found that bupropion was an effective treatment for smoking cessation. ¹¹⁰  

Only a small number of studies have examined the effectiveness of nicotine replacement therapies and/or bupropion among Indigenous Australians, and have found success rates between 6–19%—in New South Wales (two studies), ^23,111  Queensland (one study), ⁶⁶  Northern Territory (one study) ³³   and Victoria (one study). ¹¹²   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 some kind of ongoing counselling or support. Although the quit rates are lower than those reported for other populations in the medical literature, ¹⁰⁶  these studies provide evidence that assisted availability of nicotine replacement therapy, in combination with appropriate cessation support counselling, could benefit some Indigenous smokers. Several studies challenge the common perception that Indigenous people tend to be heavy smokers, and suggest that nicotine replacement therapy prescription should not assume that Indigenous 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, ^113–115   or on the Fagerström Test for Nicotine Dependence ^116–117 ) for whom nicotine replacement therapy prescription would not necessarily be appropriate.

Several studies have also surveyed Indigenous Australians regarding their attitudes to and beliefs about pharmacological cessation assistance. In 2001, the National Aboriginal and Torres Strait Islander Tobacco Control Project spoke to 275 Aboriginal people and Torres Strait Islanders around the country and reported 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. ¹⁸   Similarly, a study in six remote Northern Territory communities involving 25 community members and 19 health staff reported that knowledge about how nicotine replacement therapy works was low. ¹²  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; ¹²  health staff report a lack of knowledge and confidence in prescribing; ¹²  poor patient compliance—patients would not return for new supplies, or would run out after sharing their nicotine replacement therapy with other family members; ¹²  and cost. ^12,18   

Research in 2012–13 explored past and intended use of NRT, varenicline, and bupropion. Nicotine patches were most commonly used among a national sample of Indigenous Australians, followed by varenicline and nicotine gum. Despite similar proportions believing that they can help smokers quit, compared with non-Indigenous daily smokers, fewer Aboriginal and Torres Strait Islander daily smokers had ever used any NRT or medications (37% v 58.5%), or used them in the past year (23% v 42.1%), and these proportions were lower again for socioeconomically disadvantaged Indigenous smokers. ¹¹⁸  Activities that are likely to improve the success of nicotine replacement therapy in helping Indigenous smokers to quit are: providing better information to patients and the community; ^12,18   providing nicotine replacement therapy as part of a comprehensive tobacco cessation program; ¹⁸  providing ongoing support and counselling to patients through regular face-to-face meetings; ¹²  and providing nicotine replacement therapy free of charge to Indigenous smokers wanting to quit. ^12,18,86   

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). ¹¹⁹  However, 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. ⁷⁶  Among those surveyed in 2012–13, the majority of Indigenous people had obtained their last NRT free of cost. ¹¹⁸  However, some Indigenous 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— see Section 8.10.4 ) will remain.  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; ¹²⁰  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, ¹²¹  meaning they were ineligible for the incentive.

8.10.8 Quitlines

Quitlines, when used as a component of anti-smoking campaigns, are cost effective and increase quit rates, particularly when multiple calls are made. ¹²²  There is international evidence that quitlines can be acceptable to and effective for Indigenous peoples. ^123–126  An evaluation of Aboriginal and Torres Strait Islander utilisation of the South Australian Quitline found that similar proportions of Indigenous and non-Indigenous smokers registered for the service, and demographic variables and smoking addiction were also similar. However, Indigenous 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 conclude that Indigenous Australians appear to be less engaged with the quitline, and suggest that tailoring the service might improve engagement. ¹²⁷  Other studies have shown that quitline services may be enhanced for Indigenous people through cultural awareness and competency training of staff, ¹²³   the availability of Indigenous quitline counsellors, ¹²⁴   the provision of nicotine replacement therapy in conjunction with telephone counselling, ^123,124  and when broader anti-smoking campaigns are targeted to culturally specific groups. ¹²⁶  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. ¹¹²  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). ¹²⁸

8.10.9 Quit support groups and rehabilitation-style programs

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 Indigenous ex-smoker and perhaps open only to Indigenous people, would build upon sense of community and be likely to increase the success of quit attempts. ^27,86  The concept of rehabilitation-style programs, like those offered for alcohol and other drug withdrawal, has also been raised as a possibility. ¹⁸  

There has been limited evaluation of quit support group programs for Aboriginal peoples and Torres Strait Islanders, 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. ¹¹²   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. ¹²⁹  

An evaluation in NSW of ‘Give up the Smokes’—a culturally-appropriate group smoking cessation program for Indigenous Australians—reported a 30% quit rate after three months, which is comparable to cessation outcomes in non-Indigenous populations. ¹³⁰  A study in remote North Queensland offered assistance to local councils to implement the ‘Smoke Rings’ group support program for Indigenous 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. ⁶⁵   

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 Indigenous 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. ¹²  

8.10.10 Role of remote community shops

As part of the 1999–2000 evaluation of a Northern Territory tobacco action project, researchers assessed the potential role of remote community stores to be involved in health promotion programs around tobacco action. Findings from the study suggest that community shops serving remote communities may potentially assist in tobacco control by supporting community tobacco action programs, through displaying or providing anti-tobacco health promotion materials, implementing smokefree policies, and providing staff with training to deliver cessation advice. Pricing policies adopted by community stores may also affect tobacco sales, although this is an area requiring further research. ¹³¹  One study examined the effects of “income management” on sales of tobacco in 10 remote Indigenous communities in the 18 months before and after the introduction of the Northern Territory Emergency Response. Income management strategies restrict the purchase of certain products, including cigarettes and tobacco, on 50 per cent of welfare recipients benefits aiming to encourage the sale of healthy food. The Income Management evaluation found no beneficial effect in terms of sustained change in the sales of healthy food, soft drink or tobacco resulting from the strategy. It did, however, find that there was a marked increase in all store sales with the government stimulus package. These findings suggest that income management alone will not lead to modification of spending patterns. ¹³²  

8.10.11 Social marketing

Mainstream social marketing campaigns, when well-funded and sustained over time, have been effective at reducing smoking prevalence. ¹³³  However, there are limited studies on the impact of mainstream media campaigns on Aboriginal peoples and Torres Strait Islanders. Evaluations of the National Tobacco Campaign found that recall of these advertisements was high, but that there was little effect on quitting attempts or on smoking cessation rates. ^27,134  A 2008 evaluation of the impact of the Bubblewrap campaign ⁱⁱ  on 198 Indigenous smokers in Western Australia also found high rates of recall. In addition, the advertisements were judged to be believable and relevant by the majority of participants, and most had thought about cutting down the amount they smoked (81%) and/or quitting (68%) as a result of seeing these advertisements. ¹³⁵   

A qualitative study involving interviews with 25 community members and 19 health service staff in remote Northern Territory communities reported good recall of mainstream anti-tobacco media messages, especially those using graphic imagery. ¹²  These findings have been replicated in a study involving 143 Indigenous and 156 non-Indigenous people who were asked to rate mainstream anti-tobacco advertisements on a scale that included message acceptance and personalised effectiveness. Indigenous people rated the mainstream advertisements higher than non-Indigenous people, and found advertisements with strong graphic imagery depicting emotive first-person narratives about the health effects of smoking particularly motivating. These findings suggest that Aboriginal and Torres Strait Islander smokers may be positively influenced by mainstream anti-smoking mass media campaigns, and that this could be a cost-effective way of impacting on smoking rates. ²⁹     

There have, over the years, been a number of examples of Indigenous-specific tobacco-related social marketing campaigns or projects. These generally take the form of an Indigenous component of a mainstream campaign or program (for example, posters or advertisements adapted with Indigenous slogans or Indigenous people on them), ^136–139   or form a component of a multi-faceted tobacco control program. ^57,140–142   Several documents have suggested general principles on which Indigenous-specific social marketing strategies could be based. ^27,28,86,95   These have been summarised in the document Developmental Research to inform the National Action to Reduce Smoking Rates Social Marketing Campaign. ²⁸  This research project involved conducting interviews and focus group discussions with more than 220 Indigenous people and 30 Aboriginal and non-Aboriginal health professionals from communities across Australia. ²⁸  It concluded that communications strategies in Indigenous anti-tobacco social marketing should place a strong focus on the benefits for family and kin of quitting, including emphasising the impact of the financial cost of smoking on the family, and the adverse effects of smoking on health and fitness on the individual smoker and their family. Delivery of these messages should use Indigenous faces, voices and imagery and frame the messages in a positive and inspirational way. In addition, messages should be delivered using clear, jargon-free and regionally appropriate language, utilise local Indigenous people, use a narrative approach, and feature true stories and real people. Messages that are framed in terms of immediacy of impact (rather than a future focus) are likely to have a greater impact. ²⁸    

Although there is limited research, a number of systematic reviews evaluating interventions for smoking cessation in international Indigenous populations have provided support for the use of culturally targeted messages. ^15,16   Several studies have documented the concerns of Indigenous people about the acceptability and efficacy of mainstream media campaigns, and discuss the need to improve the cultural and social relevance of advertisements for Indigenous people. ^12,27,28,86   One project in metropolitan and rural communities in Victoria  documented that while older Indigenous people and Indigenous health workers believed that printed materials needed to be Indigenous specific or contain Indigenous content, many young people in the study did not necessarily agree; they reported being more likely to identify with the broader youth culture than with Indigenous culture, and commented that it made no difference to them if they were given Indigenous-specific materials. ²⁷  

Revival, nurturing and continuation of Indigenous cultural heritage are strong motivating factors for some individuals and communities, and have been put forward as suitable approaches in Indigenous social marketing campaigns. In New Zealand, an anti-smoking campaign for M?ori used the slogan ‘it’s about wh?nau’ (‘it’s about extended family’) and depicted testimonials from M?ori smokers and wh?nau of ex-smokers; the focus was on immediate social consequences of smoking rather than future health consequences. The campaign was successfully recalled by smokers and their wh?nau one year after its launch, the advertisements were consistently rated as very believable or very relevant by over half of the smokers who had seen them, calls to the Quitline increased, and 54% of the smokers stated that the campaign had made them more likely to quit. ¹²⁶    

Highlighting the connection between not smoking, good health and survival may therefore be a salient message for some Aboriginal and Torres Strait Islander smokers. ⁸⁶   Although, as discussed elsewhere in this chapter, while Indigenous culture and tobacco use have long been connected, the smoking of manufactured cigarettes is an introduced activity. One project has reported that younger smokers in particular showed an interest in this message: ‘it’s not part of our culture—give it back’. ⁸⁶    

Several Indigenous community organisations in Australia have used connection to family, community and culture and the threat of smoking to these as a theme in their social marketing. Social marketing campaigns in South Australia (‘Give up smokes for good’ ¹⁴³  and ‘Stickin’ it Up the Smokes’ ¹⁴⁴  ) and the ACT (‘Beyond Today’ ¹⁴⁵  ) use images of well-known community members (although not necessarily high profile or famous) along with slogans that promote the benefits of quitting for family, community and culture. Another organisation, the Kimberley Aboriginal Medical Services Council, developed posters using the slogans: ‘Stop the Smoke! You and country are one. You poison yourself. You poison your country too!’; ‘Look, listen and learn. Tobacco smoking kills’; and ‘Traditional smoking heals. Tobacco smoking kills’. ¹⁴²  

A recent national social marketing campaign, Break the Chain, ¹⁴⁶   aimed to reduce smoking prevalence among Indigenous people, along with other disadvantaged and hard to reach groups. The campaign included TV, radio, print, and digital advertising. An evaluation of the campaign found that it achieved a high level of overall reach, with almost all Indigenous respondents exposed to at least one element of the campaign. Almost two thirds of the overall target audience had taken action as a result of exposure.  Among those exposed, one third reported cutting back on the amount smoked, one quarter had discussed smoking and health with family and friends, and more than one in ten indicated they had quit smoking. Similar proportions of respondents reported intending to take action in the future as those who had taken action. These results support the receptiveness of Indigenous Australians to social marketing campaigns, and represent an ongoing opportunity for promoting behaviour change. ¹⁴⁷   In May 2016, the Commonwealth government launched a new advertising campaign targeting Indigenous smokers. The campaign, Don’t Make Smokes Your Story, encourages Aboriginal and Torres Strait Islander people to quit both for their own health, and for the health and wellbeing of their families. ¹⁴⁸  

Practitioners and researchers in Indigenous tobacco action are clear that social marketing is an important component of a comprehensive tobacco action program, and that a social marketing approach should use a combination of mainstream and Indigenous-specific content and messages, at both national and regional/local levels. ²⁸   Data from the Talking about the Smokes project showed that most Indigenous smokers remembered recently seeing an anti-tobacco television advertisement, while just under half recalled targeted (featuring an Indigenous person or artwork) advertising and about one in six remembered seeing local, targeted advertising. Frequent recall of warning labels, news stories, and advertising was associated with concerns about health and wanting to quit, and this relationship was stronger for local and targeted advertising. These results support the use of both mainstream and targeted campaigns in encouraging quitting-related thoughts and behaviours among Indigenous Australians. ³⁰  

8.10.11.1 Social media and mobile phones

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, ^149,150  particularly when they are tailored or interactive ¹⁵¹  (see Section 7.14). The potential for using digital technologies in the production and distribution of tobacco cessation and prevention messages in Indigenous 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 Indigenous youth is increasing rapidly, including in remote communities, although many communities still experience issues with access to communication technologies and services. ¹⁵²  Mobile phone messaging to disseminate smoking cessation messages and support appears to be acceptable to M āori people, including young people. ^153-154  A study involving M āori and non-M āori 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 M āori as with non-M āori. ¹⁵⁴   

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 Indigenous 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 Indigenous Australians is needed. ¹⁵⁵  The authors summarise the apps and social media programs with a focus on Indigenous Australians as follows:  

8.10.12 Secondhand smoke

High smoking rates make exposure to secondhand smoke a health issue for many Aboriginal peoples and Torres Straits Islanders, particularly infants and children (see Section 8.7.4). Although there have been notable increases in the number of Indigenous smokefree homes over time, ¹⁵⁶  in 2014–15, about 13% of Indigenous children lived with someone who smoked inside the home. ¹⁵⁷  Secondhand smoke has been documented as an issue of concern to Indigenous smokers, particularly in relation to its effect on children. ⁸⁶  Several studies have described how smokers have implemented smokefree practices to protect the health of children and/or to support their own quitting attempts. ^12,158  The impact of secondhand smoke on the health of children and family has been documented as a motivator for smoking behaviour change, whether quitting, reducing the number of cigarettes smoked or smoking away from non-smokers. ^18,26,63,68  However, a 2015 study found that despite reporting smoke-free homes/cars, Indigenous mothers and their partners continued to smoke in the first year of their baby's lives, exposing them to secondhand smoke. An intervention involving home visits was not helpful in reducing the incidence of respiratory illness in the infants. ¹⁵⁹  Several other initiatives have been developed specifically for Indigenous communities around secondhand smoke, but these have not been evaluated. ^57,139  Findings from Arnhem Land in the Northern Territory suggested greater local ownership of smokefree policies and grassroots development of strategies that incorporate cultural contexts can help create more effective management of secondhand smoke. ¹⁶⁰  

Smokefree workplaces have been found in mainstream studies to reduce exposure to secondhand smoke and to reduce cigarette consumption, increase the rate of quit attempts, and reduce the rates of relapse in smokers who are attempting to quit. ^161,162  Smokefree policies in Indigenous health services can support other tobacco action activities by contributing to the denormalisation of tobacco use within Indigenous communities, supporting Aboriginal health workers and patients who smoke to quit, and reducing exposure to secondhand smoke. Many Aboriginal community controlled health organisations around the country have developed and implemented smokefree workplace policies. Further, research in remote North Queensland found that although many businesses lacked formal smokefree policies, many had smokefree areas or informal policies in place. Community knowledge of smokefree areas was high, suggesting that informal policies are effective among Indigenous communities. ⁶⁵   

There has been no evaluation specifically of the impact of these smokefree policies on quit rates (as they are generally one of several components of comprehensive tobacco action programs), but several services have documented the processes of developing and implementing these policies. ^49,54,163  Anecdotally, the challenges in this area are largely around implementing the smokefree policies; Aboriginal health workers have reported difficulties in requesting compliance from community members, particularly when the community has not been engaged in the process. ⁸⁷  

8.10.13 Specific sub-populations

8.10.13.1 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. ^54,163  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. ¹⁶⁴  

8.10.13.2 Youth and children

Reviews of mainstream studies have found that there is limited evidence for the effectiveness of school-based programs for smoking prevention among youth when the programs are based on information giving or developing general social competence, ¹⁶⁵  but that co-ordinated, widespread, multi-component community interventions are effective. ¹⁶⁶   Mass media campaigns may also be effective for young people when well researched and appropriately developed and delivered. ¹⁶⁷  

Smoking prevention programs aimed at children are recognised as a priority area for action by many Indigenous people. ^18,26,86  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. ¹⁸   

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. ¹⁶⁸  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. ^26,169  Reducing the social acceptability of smoking in Indigenous 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. Indigenous participants in an evaluation of the National Tobacco Campaign felt that the emphasis of tobaccocontrol 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. ²⁷  

While there have been several tobacco action initiatives that target Indigenous young people, none have been evaluated for their impact on smoking uptake. Some of these programs have been school based,168, 170 while others have been community based, ¹⁷¹  or part of multi-component programs. ^{46,51,62,66,172,173}  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 Indigenous (and non-Indigenous) school students. ¹⁷⁴   

8.10.13.3 Pregnant women

A review of mainstream studies found that smoking interventions during pregnancy result in reduced smoking during late pregnancy, and improved birthweight. ¹⁷⁵  The majority of published studies of smoking in Indigenous pregnant women are descriptive studies (see Sections 8.3.3, 8.6 and 8.7.4). There are several projects that have focused specifically on providing training and resources: the Indigenous Women’s Project through the Asthma Foundation Western Australia; ¹³⁹  the Smoke-free Pregnancy Project—Aboriginal Women and their Families through Quit South Australia;  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 Indigenous 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%. ¹⁷⁸  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. ¹⁷⁹  

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. ^7,52  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. ⁷  The project was broadened to include the whole community because of the many influences that the family and community have on pregnant women. ⁵²  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. ¹⁸⁰  

A further component of programs with pregnant Indigenous 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. ¹⁸¹  Several programs in other countries have shown success with using incentives to assist pregnant women to quit smoking. ^182,183  A review of smoking interventions with pregnant women found that the most successful intervention appeared to be the use of incentives. ¹⁷⁵  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. ¹⁸⁴  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. ¹⁸⁵   

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 Indigenous women. ¹⁸⁶  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. ¹⁸⁷  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. ⁵³  

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. ¹⁸⁸  A study exploring views of pregnant Australian Indigenous 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. ¹⁸⁷  Research in 2015 found that although most pregnant Indigenous 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. ¹⁸⁹  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. ¹⁹⁰  

8.10.13.4 Prisoners

Traditionally, there have been very high rates of smoking by Indigenous prisoners  (see Section 8.3.5) along with significant challenges to providing tobacco control activities within prisons. ¹⁹¹  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. ¹⁹²  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. ¹⁹³  Programs should also be ongoing to accommodate the constantly changing prison population, and the changes in the readiness to quit of individual prisoners. ¹⁹²  Smoking cessation programs have been implemented within some prisons, ¹⁹¹  with some specifically targeting Indigenous prisoners, ⁶  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. ¹⁹⁵   

8.10.14 Broader legislation

State/territory and Commonwealth legislation that controls advertising and packaging, taxation and pricing, smokefree public areas, and sales has been found to be successful in the general Australian community in reducing consumption and/or access to tobacco products (see Chapter 13). However, research evaluating the impact of such legislation on smoking rates among Indigenous people is sparse. Increasing taxes on tobacco has been shown to reduce consumption in the general Australian community, and has been shown to result in a greater decline in consumption among low-income groups than among middle- and high-income groups. ¹⁹⁶  The National Aboriginal and Torres Strait Islander Tobacco Control Project raised some concerns about price increases causing financial stress that could in turn lead to greater levels of smoking. ¹⁸  In a 2007 qualitative study involving community members (25) and health staff (19) in remote Northern Territory communities, perceptions of the impact of price increases were conflicting. While participants suggested that higher prices were not a disincentive to smoking, they also talked about changing their smoking behaviour and accessing a smaller number of cigarettes when money was scarce. ¹²  In this same study, participants described the difficulties in remote communities of enforcing existing legislation around smokefree public places, and that the lack of other Northern Territory legislation was undermining their tobacco control efforts. Participants also reported good recall about the picture health warnings on tobacco products, but some reported disregarding these and employing strategies to avoid seeing the images. ¹²  Research on the effects of the 25% tobacco tax excise rise in 2010 on remote Indigenous communities found that there was strong overall support among Indigenous Australians for price increases as a means of reducing smoking. Participants also suggested that tax increases needed to be supported by other tobacco control activities and greater local cessation support. While findings regarding effects of the tax on consumption were inconclusive, participants did report adopting price minimising strategies, such as increased demand to share cigarettes. ¹⁹⁷  

There is also some research showing that plain packaging legislation appears to have similar effects on reducing pack appeal and reducing misperceptions about the relative harmfulness of cigarettes among Aboriginal and Torres Strait Islander people as the general population. One study found that, among Indigenous Australians, plain packaging had reduced misperceptions that some brands are healthier than others. Compared with pre-plain packaging, younger participants were also less likely to view some brands as more prestigious than others. ¹⁹⁸  

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