Over the past decade, the amount of 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 a broad range of 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.
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 Organisation and the Department of Health and Aged Care. 3
The most recent National Tobacco Strategy (2012–18) 17 was developed by the Intergovernmental Committee on Drugs Standing Committee on tobacco as a sub-strategy under the National Drug Strategy 2010–2015. It builds on its precursors (the National Tobacco Strategy 1999 to 2002–03, and 2004–2009), 16, 18 and emphasises that reducing smoking among Aboriginal and Torres Strait Islander people is central to closing the gap. The report highlights a range of priorities from the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, 19 which aim to reduce the harm and inequality caused by tobacco among Indigenous Australians. These include: 17
- social marketing activities to reduce smoking-related harms among Aboriginal and Torres Strait Islander people;
- Aboriginal and Torres Strait Islander specific smoking cessation and support services;
- continued regulatory efforts to encourage reduction/ cessation in smoking;
- strategies to improve delivery of smoking cessation services, including NRT;
- roll-out of a range of state and territory programs and national programs under the agreement.
Each state and territory has developed and implemented its own tobacco strategy or action plan 20-27 . These strategies recognise Aboriginal and Torres Strait Islander peoples as a target group for tobacco action. The ACT also produced the Aboriginal and Torres Strait Islander Tobacco Control Strategy, 2010/11–2013/14 28 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. 29 A key action area identified in this document is to: ‘Work in partnership with Indigenous groups to boost efforts to reduce smoking and exposure to passive smoking among Indigenous Australians’. Six actions specifically related to this were recommended (p190–2): 29
- establish multi-component community-based tobacco-control projects that are locally developed and delivered
- enhance social marketing campaigns for Indigenous smokers, ensuring a ‘twin track’ approach of using existing effective mainstream campaigns complemented by Indigenous specific campaign elements
- provide training to Aboriginal and Torres Strait Islander health workers to improve skills in the provision of smoking cessation advice
- improve training in the provision of smoking cessation advice of other health professionals working in Aboriginal and Torres Strait Islander health services
- place specialist tobacco-control workers in Indigenous community health organisations to build capacity at the local health service level to develop and deliver tobacco-control activities
- provide incentives to encourage non-government organisations to employ Indigenous workers.
In addition, a number of recommendations were made specifically around improving data collection on tobacco use and behaviours among Indigenous people (p198): 29
- increase sample sizes of the National Aboriginal and Torres Strait Islander health and social surveys to provide reliable indications of changes over time in each state and in the Northern Territory. This should be done in preference to trying to include sufficient Indigenous people in annual state population surveys
- use state population surveys to over-sample each year within two or three state health department regions with a high proportion of Indigenous residents, so that reliable estimates of prevalence at a regional level become available on a three-yearly basis
- analyse percentage changes in the prevalence of Indigenous smoking compared with percentage changes in previous periods, and compared with absolute and percentage changes in the non-Indigenous population
- extend the Australian Secondary Students’ Alcohol and Drug Survey to more remote areas of Australia and to Indigenous schools to ensure the inclusion of greater numbers of Indigenous children. This would enable a reliable indication of changes over time in Indigenous smoking in each state and territory
- establish a panel of Indigenous people who are currently smokers to enable the monitoring of intentions and attempts to quit, amounts smoked and the prevalence of smoking indoors and around others. The panel could also be used to monitor the impact of tobacco-control policies among Indigenous people.
All of these recommendations have been accepted by the Commonwealth Government, 30 with some of these being specifically addressed in the Tackling Indigenous Smoking Initiative described below.
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. 31 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: 31
- 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.
In addition to these initiatives, the Commonwealth 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. 32 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. 19
The Tackling Indigenous Smoking 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: 32, 33
- 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. 34 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. 35
Following a 2014 review, 36 the Tackling Indigenous Smoking 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 Tackling Indigenous smoking program had a budget of $116.8 million over 3 years from 2015-16 and included: 37
- 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 ProgramEvaluation and Monitoring Framework; and
- special projects with sub-populations of significant disadvantage and high smoking rates.
The final evaluation report of the Tackling Indigenous Smoking 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 11 th 2018, the Australian Government announced that the Tackling Indigenous Smoking program would continue, with a commitment of $183.7 million over 2018-19 to 2021-22. 38
8.13.6 The Aboriginal and Torres Strait Islander Health Plan 2013–2023
The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 39 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
A progress report released in July 2019 indicated that each of these five goals is so far on track. 40 Specifically,:
- The rate in 2016 (42.8%) of Aboriginal and Torres Strait Islander women who smoke during pregnancy was similar to the trajectory point required to meet goal 3 (43.4%)
- The rate in 2014–15 (17.2%) of Aboriginal and Torres Strait Islander youth aged 15–17 years who smoke was similar to the required trajectory point to meet goal 9 (16.5%)
- In 2014–15, the rate of Indigenous people aged 15–17 who had never smoked (78%) was below the trajectory point required to meet goal 10 (80%). However, taking into account sampling error associated with the survey data, the goal can be considered on track
- The proportion of Indigenous people aged 18–24 who had never smoked has increased over time—from 34% in 2002 to 46% in 2014–15. The rate for 2014–15 was above the required trajectory point to meet goal 11 (44%)
- The proportion of Indigenous people aged 18 and over who reported smoking tobacco decreased between 2002 and 2014–15 (from 49% to 43%). The rate in 2014–15 was similar to the trajectory point required to meet goal 12 (43%)
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