8.13 Policies for advancing tobacco control programs among Aboriginal and Torres Strait Islander peoples

Last updated: May 2023
Suggested citation: van der Sterren, A, Greenhalgh, EM, Jenkins, S, Knoche, D, & Winstanley, MH 8.13 Policies for advancing tobacco control programs among Aboriginal and Torres Strait Islander peoples. In Greenhalgh EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from http://www.tobaccoinaustralia.org.au/chapter-8-aptsi/8-13-policy-recommendations-for-advancing-tobacco- 

 

Over the past decade, information about the use of tobacco and its impact on the health and wellbeing of Aboriginal and Torres Strait Islander populations has increased dramatically. The preceding sections have drawn on many different research reports, some of which have made specific recommendations about appropriate policy directions for effective tobacco interventions in the Indigenous population.1-10 These reports and the many community members, health professionals, researchers, and policy-makers working in the area of Indigenous tobacco control have advocated a co-ordinated policy framework and action in this area supported by adequate and sustained funding. Commonwealth, state and territory governments have responded to these calls and to the emerging evidence of the harms of smoking in Indigenous communities. In the context of a public health policy environment with an increased emphasis on preventive health and a commitment to reducing Indigenous disadvantage, Australian governments at all levels have taken a co-ordinated approach to Indigenous smoking and have committed significant funding to support it. The Tackling Indigenous Smoking program will be described further below, but first it is important to have a sense of the broader policy environment relevant to Indigenous tobacco control, including the international and national policy contexts. This section covers:

8.13.1 The Framework Convention on Tobacco Control

Action on tobacco in Aboriginal and Torres Strait Islander communities does not happen in isolation of Australia’s obligations on the international policy stage. As a signatory to the World Health Organization Framework Convention on Tobacco Control (FCTC), the Australian Government has committed to ensuring that:

“Every person…be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke and effective legislative, executive, administrative or other measures should be contemplated at the appropriate governmental level to protect all persons from exposure to tobacco smoke” (Article 4.1).11

Furthermore, the FCTC specifically expresses that Parties to the Convention are ‘Deeply concerned about the high levels of smoking and other forms of tobacco consumption by indigenous peoples’ (p2).11 The Convention commits signatories to develop and support multisectoral measures and co-ordinated responses that take into consideration ‘the need to take measures to promote the participation of indigenous individuals and communities in the development, implementation and evaluation of tobacco control programmes that are socially and culturally appropriate to their needs and perspectives’ (p6).11

8.13.2 The National Drug Strategy 2017–2026 and the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014–19

Current national drug policy (including both licit and illicit substances) is embodied in the National Drug Strategy 2017–2026.12 Since its inception in 1985, the National Drug Strategy has advocated a harm minimisation approach with the three pillars of demand reduction, supply reduction and harm reduction. A sub-strategy of the National Drug Strategy is the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014–19 that builds upon an earlier Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009.13 The sub-strategy sets out four priority areas directed at reducing alcohol and drug use and their related harms, and at reducing the proportion of Aboriginal peoples and Torres Strait Islanders who smoke tobacco:14

  • Build capacity and capability of AOD services and its workforce as part of a cross-sectoral approach;
  • Increase access to a full range of culturally responsive appropriate prevention programs and interventions aimed at the local needs of individuals, families and communities;
  • Strengthen partnerships based on respect between communities, including in law enforcement and health organisations, at all levels of planning, delivery and evaluation; and
  • Establish meaningful performance measures with effective data systems that support community-led monitoring and evaluation.

8.13.3 The National Tobacco Strategy and state/territory tobacco strategies

The National Tobacco Strategy is a policy framework for the Australian Government and state and territory governments to work together and in collaboration with non-government agencies to improve health and to reduce the social costs caused by tobacco.15 The first National Tobacco Strategy (1999 to 2002–03)16 recognised that concerted action was required to reduce smoking prevalence among Aboriginal and Torres Strait Islander communities. This led to the funding and launch in 2000 of the National Aboriginal and Torres Strait Islander Tobacco Control Project, a joint initiative between the National Aboriginal Community Controlled Health Organisationi and the Department of Health and Aged Care.3

The National Tobacco Strategy (2023–30)15, 17 was developed with oversight from all Australian governments as a sub-strategy under the National Drug Strategy 2017–2026  and also complements the National Preventive Health Strategy 2021–2030 . It builds on previous strategies (the National Tobacco Strategy 1999 to 2002–03, 2004–2009 and 2012–2018)16-18, in particular the National Tobacco Strategy 2012–2018’s midpoint review,19  and aims to align with the priority reform areas of the National Agreement on Closing the Gap.20 A key action area identified in this document is to: ‘Strengthen and expand efforts and partnerships to prevent and reduce tobacco use among First Nations people' (Priority 4). Ten actions were listed to address this priority:

  • “continue existing Commonwealth investment in multifaceted and culturally safe approaches to reduce tobacco use among First Nations people, and expand state and territory investments to complement and reinforce these approaches”;
  • “monitor and evaluate the effects of initiatives to improve programs and policies to accelerate reduction in tobacco use among First Nations people”;
  • “continue to build tobacco control capability and capacity for First Nations communities in Aboriginal community-controlled organisations and mainstream services”;
  • “support First Nations organisations in their efforts to promote the benefits of being smoke free, as reflected in their organisational policies and community programs;
  • strengthen partnerships and collaboration between First Nations organisations, governments and NGOs”;
  • “continue to provide training to First Nations health workers, health professionals (such as GPs) and other relevant workers on effective tobacco control interventions”;
  • “deliver best practice and culturally safe education, intervention, screening, and tobacco and nicotine cessation as part of all routine health service delivery and social and community service provision to First Nations clients”;
  • “ensure First Nations people have appropriate access to culturally safe cessation supports and subsidised nicotine replacement therapy, identifying, mitigating and/ or addressing barriers to access and uptake of services supporting tobacco and nicotine cessation”;
  • “encourage and support people from First Nations priority groups (i.e., pregnant people, young people, remote populations and prisoners) and their families to be smoke free or quit smoking. This includes providing messages about tobacco-related harms and the harms associated with second-hand smoke exposure”;
  • “enhance, implement and evaluate evidence-based integrated public health campaigns for First Nations people by complementing them, where appropriate, with campaign elements tailored to First Nations people and with local community-specific campaigns”.15

Each state and territory has developed and implemented its own tobacco strategy or action plan (see Appendix 1.4 - Australian tobacco control strategies and documentation). These strategies recognise Aboriginal and Torres Strait Islander peoples as a priority group for tobacco action. The ACT also produced the Aboriginal and Torres Strait Islander Tobacco Control Strategy, 2010/11–2013/1421 and several states have developed advisory mechanisms for the development and implementation of tobacco strategies for Indigenous peoples.

8.13.4 National Preventative Health Strategy

The national Preventative Health Taskforce was established in April 2008 to develop a National Preventative Health Strategy focusing on three priority areas for action: obesity, alcohol, and tobacco. In June 2009, the Taskforce released Australia: The Healthiest Country by 2020—National Preventative Health Strategy—The Roadmap for Action.22 The strategy recommended several actions relating to working in partnership with Indigenous groups to boost efforts to reduce smoking and exposure to passive smoking and improving data collection on tobacco use and behaviours among Indigenous people.22 These recommendations were accepted by the Commonwealth Government,23 with some of these being specifically addressed in the Tackling Indigenous Smoking Initiative described in Section 8.13.5.

The National Preventative Health Strategy 2021-2030 was launched by the Australian Government in December 2021. The strategy has set a target to decrease the prevalence of daily smoking among Aboriginal and Torres Strait Islander people aged 15 and older to 27% or less by 2030.24

8.13.5 The Tackling Indigenous Smoking Initiative

In 2008, the Council of Australian Governments committed to targets for closing the gap on Indigenous disadvantage in the areas of health, education, and employment. These targets included closing the life expectancy gap within a generation, and halving the gap in mortality for Indigenous children under five within a decade. Recognising the contribution of smoking to the health gap, ‘Tackling Smoking’ became a key initiative of the Council of Australian Governments’ National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.25 Commonwealth, state and territory governments committed a total of almost $200 million over four years (2009–13) to reduce the smoking rate and the tobacco-related burden of disease within Aboriginal and Torres Strait Islander communities—$100.6 million from the Commonwealth Government and $98.09 million from the states and territories. This was to be achieved through:

  • social marketing campaigns to reduce smoking-related harms
  • Indigenous-specific smoking cessation and support services
  • continued regulatory efforts to encourage reduction/cessation in smoking
  • strategies to improve delivery of smoking cessation services, including nicotine replacement therapy.25

In addition to these initiatives, the Australian Government provided a further $14.5 million over the same four-year period for 18 Indigenous tobacco-specific projects under the Indigenous Tobacco Control Initiative.26 A 2013 review of the first three years of the National Partnership Agreement stated that at that point it was too early to assess whether it had achieved its intended outcomes in terms of improvements to Indigenous health. Early evidence indicated improved access to healthcare, and there had been good progress in the implementation of initiatives and activities by all governments.27

The Tackling Indigenous Smoking (TIS) Initiative was part of the Indigenous Chronic Disease Package (ICDP), a broader set of strategies to address chronic diseases and risk factors more generally. In the area of smoking, the following activities were planned under the leadership of a National Co-ordinator for Tackling Indigenous Smoking:26, 28

  • a staged roll-out of tobacco action workers (TAW) and Regional Tobacco Co-ordinators (RTC) across 57 regions (to work as part of teams with the Healthy Lifestyle Workers funded through another component of the Indigenous Chronic Disease Package);
  • training to support these positions (TAWs and RTCs) to deliver smoking cessation programs and supports in Indigenous communities;
  • training for the new and existing workforce in providing brief interventions in smoking;
  • training, funding and supports to the TAWs and RTCs to develop and implement localised anti-smoking social marketing campaigns;
  • quit smoking role models and ambassadors at the local level to assist other smokers to quit;
  • an enhancement of Quitline services to be more accessible to and appropriate for Aboriginal and Torres Strait Islander people;
  • social marketing campaigns for Indigenous people.

The 2013 Prime Minister’s Closing the Gap report indicated that by the end of 2012–13, Regional Tackling Smoking and Healthy Lifestyle Teams were expected to have national coverage. Nationally more than 200 health workers and community educators were trained in smoking cessation, and Quitlines were enhanced to provide more culturally appropriate services for Aboriginal and Torres Strait Islander people, including specific Indigenous positions and cultural awareness training for staff.29 A 2014 evaluation of the ICDP indicated that it has increased the focus on health promotion and preventive health among Indigenous communities, which has resulted in community members now seeking more help to, for example, quit smoking. Clinicians reported an increased interest from patients in cessation support, along with an increase in the use of smoking cessation medicines. One in three program managers reported behavioural changes among the target community members, including smoking cessation. However, health workers reported a need for long-term, sustained programs with consistent staff, which is reportedly difficult in a remote context. Aboriginal health workers also reported considerable challenges in implementing and enforcing smokefree policies at Aboriginal Health Services.30

Following a 2014 review,31 the TIS and Healthy Lifestyle program was redesigned to support flexible approaches to regional tobacco control. The redesigned program shifted funding away from dedicated healthy lifestyles workers delivering

broader healthy lifestyle activities, toward funding for programs and activities that have a primary focus on tobacco reduction outcomes. The TIS program had a budget of $116.8 million over 3 years from 2015–16 and included:32

  • regional tobacco control grants to support multi-level approaches to tobacco control that are locally designed and delivered;
  • a National Best Practice Unit (NBPU) to support regional tobacco control grant recipients through evidence-based resource sharing, information dissemination, advice and mentoring, workforce development, and monitoring and evaluation;
  • National Tackling Indigenous Smoking Coordinator;
  • enhancement to existing Quitline services;
  • brief intervention training to frontline community and health workers;
  • program evaluation and monitoring including the development of a Program Evaluation and Monitoring Framework; and
  • special projects with sub-populations of significant disadvantage and high smoking rates.

The final evaluation report of the TIS Program was published in 2018 and concluded that the redesigned program was successful in meeting its short-term outcomes. Its flexible design and place-based, population health approach was found to be culturally appropriate and helpful in reducing the high smoking rates among Aboriginal and Torres Strait Islander peoples. In meeting its short-term desired outcomes, the program was evaluated as on track to achieving its medium- and long-term desired outcomes, which include a reduction in exposure to second-hand smoke and a reduction in the gap in prevalence of smoking between Aboriginal and Torres Strait Islander people and non-Indigenous people. On February 11th 2018, the Australian Government announced that the TIS program would continue, with a commitment of $183.7 million over 2018–19 to 2021–22.33

An evaluation of Tackling Indigenous Smoking Program’s Regional Tobacco Control Grants and Remote Priority Group Grants programs over 2018-19 to 2021-22 was the published in June 2022. The evaluation determined that both programs had achieved their intended short-term outcomes and showed some advancement towards medium-term goals. As a result, it was concluded that the TIS program should continue to receive funding, while acknowledging the need for certain improvements in team planning, reporting and evaluation, community engagement, focus on priority groups and referrals to locally appropriate quit support services.34, 35 On May 2nd 2023, the Australian Government announced the Tackling Indigenous Smoking program would be extended and expanded to address vaping and smoking, with a commitment of $141 million.36

8.13.6 The Aboriginal and Torres Strait Islander Health Plan 2013–2023

The National Aboriginal and Torres Strait Islander Health Plan 2013–202337 is an evidence-based policy framework designed to guide policies and programs to improve Aboriginal and Torres Strait Islander health. In October 2015, the Australian Government released the Implementation Plan for the Health Plan, which set twenty goals to be achieved by 2023. Five of the goals relate to smoking:

  • Goal 3: Decrease the rate of Aboriginal and Torres Strait Islander women who smoke during pregnancy from 47% in 2012 to 37% by 2023
  • Goal 9: Reduce the rate of Aboriginal and Torres Strait Islander youth aged 15–17 years who smoke from 19% in 2012–13 to 9% by 2023
  • Goal 10: Increase the rate of Aboriginal and Torres Strait Islander youth aged 15–17 years who have never smoked from 77% in 2012–13 to 91% by 2023
  • Goal 11: Increase the rate of Aboriginal and Torres Strait Islander youth aged 18–24 years who have never smoked from 42% in 2012–13 to 52% by 2023
  • Goal 12: Reduce the smoking rate among Aboriginal and Torres Strait Islander people aged 18 plus from 44% in 2012–13 to 40% by 2023.

The progress update released in December 2021 indicated that four of these five goals were on track.38 Specifically:

  • The prevalence in 2019 (44%) of Aboriginal and Torres Strait Islander women smoking during pregnancy was below the trajectory point required to meet goal 3 (41%).
  • The prevalence in 2018–19 (13.0%) of Aboriginal and Torres Strait Islander youth aged 15–17 years who smoke was similar to the required trajectory point to meet goal 9 (12.8%).
  • The prevalence in 2018–19 (84.6%) of Aboriginal and Torres Strait Islander youth aged 15–17 years who had never smoked was slighty below the trajectory point required to meet goal 10 (85.6%). However, taking into account sampling error associated with the survey data, the goal can be considered on track.
  • The proportion in 2018-19 (50%) of Aboriginal and Torres Strait Islander people aged 18–24 who had never smoked was above the required trajectory point to meet goal 11 (48%)
  • The proportion in 2018-19 (43%) of Aboriginal and Torres Strait Islander people aged 18 and over who reported smoking tobacco was similar to the trajectory point to meet goal 12 (42%), taking into account sampling error associated with the survey data.


i National Aboriginal Community Controlled Health Organisation is the peak national body representing Aboriginal community controlled health services. See: http://www.naccho.org.au/


Relevant news and research

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References

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