Last updated: March 2021
Suggested citation: van der Sterren, A, Greenhalgh, EM, Knoche, D, & Winstanley, MH 8.14 The effectiveness of population-level tobacco control strategies. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from: https://www.tobaccoinaustralia.org.au/chapter-8-aptsi/8-14-the-effectiveness-of-population-level-tobacco-control-strategies
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 current Tackling Indigenous Smoking program has a budget of $183.7 million over four years until 2022 (see Section 8.13.5).
There is robust evidence that population-wide strategies such as anti-smoking advertisements, smokefree policies, and increases in taxes on cigarettes have reduced the prevalence of smoking in Australia. Although research examining the effects of such policies on smoking among Aboriginal and Torres Strait Islander peoples is sparse, limited evidence suggests that they can promote cessation. This section summarises evidence on:
- Price increases
- Graphic health warnings and plain packaging
- Mass media campaigns
- Smokefree policies, and
- Harm reduction approaches
8.14.1 Price increases
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.10 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.11 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
Research on the effects of the 25% tobacco tax excise rise in 2010 on remote Aboriginal and Torres Strait Islander communities found that there was strong overall support among Aboriginal and Torres Strait Islander peoples 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.13
8.14.2 Graphic health warnings and plain packaging
Participants in a 2007 qualitative study in remote Northern Territory communities 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 More recent research has shown 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 peoples as the general population. One study found that, among Aboriginal and Torres Strait Islander peoples, 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.14
8.14.3 Mass media campaigns
Mainstream social marketing campaigns, when well-funded and sustained over time, have been effective at reducing smoking prevalence.15 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.16, 17 A 2008 evaluation of the impact of the Bubblewrap campaign i on 198 Aboriginal and Torres Strait Islander 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.18
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 Aboriginal and Torres Strait Islander and 156 non-Indigenous people who were asked to rate mainstream anti-tobacco advertisements on a scale that included message acceptance and personalised effectiveness. Aboriginal and Torres Strait Islander peoples 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.19
There have, over the years, been a number of examples of Aboriginal and Torres Strait Islander-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),20-23 or form a component of a multi-faceted tobacco control program.24-27 Several documents have suggested general principles on which Aboriginal and Torres Strait Islander-specific social marketing strategies could be based.16, 28-30 These were summarised in the document Developmental Research to inform the National Action to Reduce Smoking Rates Social Marketing Campaign.30 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.30 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 Aboriginal and Torres Strait Islander 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.30
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.31, 32 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, 16, 28, 30 One project in metropolitan and rural communities in Victoria documented that while older Aboriginal and Torres Strait Islander peoples and health workers believed that printed materials needed to be Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander culture, and commented that it made no difference to them if they were given Indigenous-specific materials.16
Revival, nurturing and continuation of Aboriginal and Torres Strait Islander 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 Māori used the slogan ‘it’s about whānau’ (‘it’s about extended family’) and depicted testimonials from Māori smokers and whānau 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 whānau 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.33
Highlighting the connection between not smoking, good health and survival may therefore be a salient message for some Aboriginal and Torres Strait Islander smokers.28 Although, as discussed elsewhere in this chapter, while Aboriginal and Torres Strait Islander 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’.28
Several Aboriginal and Torres Strait Islander 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’34 and ‘Stickin’ it Up the Smokes’35 ) and the ACT (‘Beyond Today’36 ) 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’.27
A national social marketing campaign, Break the Chain,37 aimed to reduce smoking prevalence among Aboriginal and Torres Strait Islander people. 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 Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander Australians to social marketing campaigns, and represent an ongoing opportunity for promoting behaviour change.38
In May 2016, the Commonwealth government launched a new advertising campaign targeting Aboriginal and Torres Strait Islander 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.39 Evaluations in 2016,40 2017,41 and 201842 consistently showed high awareness and reach of the campaign among Aboriginal and Torres Strait Islander peoples, and that it was effective in prompting cessation intentions and behaviours. In 2018, amongst Aboriginal and Torres Strait Islander respondents who recognised the campaign, 7% stated that they had quit as a result, 26% had reduced the amount they smoke, and 14% had discussed smoking with family and friends. Further, one in five Aboriginal and Torres Strait Islander respondents stated they intended to quit smoking, and another one in five intended to reduce the amount they smoke, because of the campaign. During the campaign period there was a 25% increase in the number of visits to the Quit Now website, a 13% increase in calls made to the Quitline and a 43% increase in downloads of the My QuitBuddy app.42
Practitioners and researchers in Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander -specific content and messages, at both national and regional/local levels.30 Data from the Talking about the Smokes project showed that most Aboriginal and Torres Strait Islander smokers remembered recently seeing an anti-tobacco television advertisement, while just under half recalled targeted (featuring an Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander peoples.43
8.14.4 Smokefree policies
High smoking rates make exposure to secondhand smoke a health issue for many Aboriginal and Torres Straits Islander peoples, particularly infants and children (see Section 8.7.4). Although there have been notable increases in the number of Aboriginal and Torres Strait Islander smokefree homes over time,44 in 2014–15, about 13% of Aboriginal and Torres Strait Islander children lived with someone who smoked inside the home.45 In 2012–3, 56% of Aboriginal and Torres Strait Islander smokers and 80% of non-smokers reported that smoking was banned in their home. Smokers who live in smokefree home are more likely to want to and have made quit attempts.46
Secondhand smoke has been documented as an issue of concern to Aboriginal and Torres Strait Islander smokers, particularly in relation to its effect on children.28 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, 47 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.11, 48-50 However, a 2015 study found that despite reporting smokefree homes/cars, Aboriginal and Torres Strait Islander mothers and their partners continued to smoke in the first year of their baby's lives. An intervention involving home visits was not helpful in reducing the incidence of respiratory illness in the infants.51 Several other initiatives have been developed specifically for Aboriginal and Torres Strait Islander communities around secondhand smoke, but these have not been evaluated.23, 24 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.52
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.53, 54 In 2012-3, most Aboriginal and Torres Strait Islander people who smoked daily (88%) reported that their workplace had indoor smoking bans. Smokers working in smokefree environments were 2.85 times as likely to have smoke-free home as well.46
Smokefree policies in Aboriginal and Torres Strait Islander health services can support other tobacco action activities by contributing to the denormalisation of tobacco use within Aboriginal and Torres Strait Islander 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 Aboriginal and Torres Strait Islander communities.55
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.56-58 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.59 In a 2007 qualitative study involving community members (25) and health staff (19) in remote Northern Territory communities, 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.12
8.14.5 Harm reduction approaches
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 Aboriginal and Torres Strait Islander smokers, particularly in studies of pregnant smokers, as a conscious strategy to reduce tobacco-related harm;48, 49 however, this approach is not recommended by peak public health organisations,60, 61 as even 'light' smoking is associated with substantially elevated risks of disease and death (see Section 18.3). Cutting down, particularly when combined with nicotine replacement therapy, appears to be more useful as a step toward quitting.62
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.63 Some researchers have argued 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.
See Chapter 18 for a detailed discussion of harm reduction in tobacco control.
i The television advertisement portrayed a piece of bubblewrap in the shape of lungs and showed a hand burning the bubbles with a lit cigarette. The voiceover explained that the chemicals in tobacco smoke destroy the tiny air sacs in the lungs.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated March 2021)
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21. Cancer Council Western Australia. History in the making: the first 10 years of the Make Smoking History campaign. Perth, Australia: CCWA, 2010. Available from: https://www.cancerwa.asn.au/resources/2019-12-17-Make-Smoking-History-10th-Anniversary-Book.pdf
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27. Kimberley Aboriginal Medical Services Council. Resources—Beyond the Big Smoke. 2010. Available from: https://aodknowledgecentre.ecu.edu.au/key-resources/programs-and-projects/538/?title=Beyond+the+Big+Smoke
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30. Ipsos-Eureka Social Research Institute and Winangali, Developmental research to inform the National Action to Reduce Smoking Rates social marketing campaign. . Prepared for the Department of Health and Ageing Sydney: Ipsos-Eureka Soc ia l Research Institute and Winangali; 2010.
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38. Orima Research, National Tobacco Campaign--More targeted approach & Break the Chain. Campaign evaluation. Department of Health; 2014.
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