8.3 Prevalence of tobacco use among Aboriginal peoples and Torres Strait Islanders

Last updated: February 2020

Suggested citation: van der Sterren, A, Greenhalgh, EM, Hanley-Jones, S, Knoche, D, & Winstanley, MH 8.3 Prevalence of tobacco use 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; 2020. Available from http://www.tobaccoinaustralia.org.au/chapter-8-aptsi/8-3-prevalence-of-tobacco-use-among-aboriginal-peo

 

8.3 Prevalence of tobacco use among Aboriginal and Torres Strait Islander peoples

Tobacco use is widespread among Aboriginal and Torres Strait Islander populations,1 although prevalence varies between regions and communities across Australia. The first major national study measuring smoking prevalence in the Indigenous population was the National Aboriginal and Torres Strait Islander Survey of 1994,2 subsequently updated with the National Aboriginal and Torres Strait Islander Social Surveys of 2002, 2008, and 2014–15.3-5 The National Health Surveys of 19956 and 20017 also provide data on smoking rates, and the National Aboriginal and Torres Strait Islander Health Surveys for 2004‒05,8 2012–131 and 2018–199 have been added to this series, expanding on the Indigenous component of the earlier National Health Survey reports. As the most recent report in these series, most of the data presented in this section come from the National Aboriginal and Torres Strait Islander Social Survey, 2014–155 and the National Aboriginal and Torres Strait Islander Health Survey for 2018–199. Data from the National Aboriginal and Torres Strait Islander Social Survey, 2014–155 and the National Aboriginal and Torres Strait Islander Health Survey for 2012–13 have also been used to estimate smoking prevalence among the Stolen Generations and their descendants.10

This section includes estimates of current smoking prevalence among Aboriginal and Torres Strait Islander peoples, as well as prevalence over time. It also reports prevalence among Indigenous peoples living in remote areas and by socioeconomic indicators, as well as among pregnant women, health workers, and prison populations. Smoking rates among Indigenous populations in other countries are also reported.

8.3.1 Latest estimates of smoking prevalence

Table 8.3.1 shows the prevalence of daily smoking in 2018–19 by sex, Indigenous status, and age group. When compared to the overall Australian population in 2017–18, Aboriginal and Torres Strait Islander peoples have a substantially higher prevalence of smoking for all age groups among both men and women. Thirty-eight per cent of the combined Aboriginal and Torres Strait Islander population aged 15 and over were daily smokers, compared with 13% of the non-Indigenous population.9 After adjusting for differences in age structure, Aboriginal and Torres Strait Islander peoples aged 15 years and over were almost three times as likely as non-Indigenous people to be daily smokers.9 Prevalence of daily smoking for people 18 years and over appeared to be similar among Aboriginal peoples (40.5%) and Torres Strait Islander people (40.6%). The proportion of Aboriginal and Torres Strait Islander peoples aged 15 years and over who smoked every day was about the same for males (39%) and females (36%).9

Age standardised. See Table 11.3 in Australian Bureau of Statistics. 4715.0 - National Aboriginal and Torres Strait Islander Health Survey, 2018-19: Smoking. ABS, 2019

Table 8.3.1 Percentage (rounded) of current daily smoking* among Aboriginal and Torres Strait Islander peoples by sex, Indigenous status and age group, 2018–19

 

Indigenous status

Age group

15‒17

18-24

25‒34

35‒44

45‒54

55–64

65–74

75+

Males

Indigenous

11.7

35.2

47.0

48.5

44.3

34.7^

Non-Indigenous

2.4

17.5

19.0

19.6

19.3

16.5

8.0

9.9

Females

Indigenous

7.8

36.0

40.7

45.0

40.6

32.4^

Non-Indigenous

1.1

10.4

10.6

12.4

14.7

13.8

6.0

7.5

*Current daily smokers are those who smoke one or more cigarettes (either manufactured or roll-your-own), cigars or pipes per day, on average. Chewing tobacco and smoking of substances other than tobacco are excluded.

^The oldest age group reported in the National Aboriginal and Torres Strait Islander Social Survey was 55+

Sources: National Aboriginal and Torres Strait Islander Health Survey, 2018-19: Smoking;9 National Health Survey: First Results, 2017-1811

Data on smoking and other preventative health indicators is also provided to the Australian Institute of Health and Welfare (AIHW) by primary health care organisations that receive funding from the Australian Government Department of Health to provide services to Aboriginal and Torres Strait Islander people. As at December 2017, 51% of Aboriginal and Torres Strait Islander regular clients aged 15 years and over were current smokers. Males across all age groups showed higher proportions of current smoker status than females, with Indigenous males aged 25-44 recording the highest prevalence at 67%. By contrast, women aged 65 years and over had the lowest prevalence of current smoking (22%) as well as the highest prevalence of never smoking (50%).12  The subgroup of Aboriginal and Torres Strait Islander peoples who were born before 1972 and who have reported being removed from their families can be used as a proxy measure for the ‘Stolen Generations’ (by 1972, relevant legislation had been repealed and removal practices had ceased). In 2014–15, 50% of the Stolen Generations proxy population reported being current smokers, compared with 40% who were not removed. There was no significant difference in current smoking prevalence between the descendants of people removed (42%) and those who had not experienced any type of removal (42%).10

8.3.2 Smoking prevalence over time

There have been progressive decreases in smoking prevalence among Indigenous Australians over time. The prevalence of current (i.e., daily + less often) smoking among Indigenous persons 15 years and over declined by 2.4% between 1994 (the first year with reliable prevalence data) and 2004, from 54.5% in 1994 to 53.5% in 2002 to 52.1% in 2004.13 There were also declines in more recent years, from 49.8% in 2008, to 45.8% in 2012–13, to 44.5% in 2014–15, and 41% in 2018–19.9, 14 Figure 8.3.1 shows current smoking among Indigenous and non-Indigenous persons since 1994.

 

 

Figure 8.3.1. Estimated prevalence of current smoking among Aboriginal and Torres Strait Islander adults and non-Indigenous persons aged 15+, 1994–2019

Source Australian Bureau of Statistics 9, 14

Between 2004–05 and 2018–19, the prevalence of daily smoking among Aboriginal and Torres Strait Islander adults 15 years and over in Australia decreased by 12.6%, from 50.0% to 37.4%.9, 15 Declines were observed among both men and women, and proportion of people who smoked every day was lowest for people age 15–17 years (10%). The proportion of Aboriginal and Torres Strait Islander peoples aged 18 years and over who smoked every day has seen a steady decrease over the last 14 years in non-remote areas, from 49% in 2004–05 to 37% in 2018–19. The proportion of smokers in remote areas did not change significantly over this time.9 

Additional encouraging data show that between 1994 and 2014–15, smoking initiation (as indicated by smoking prevalence among Aboriginal and Torres Strait Islander peoples aged 15–17 years) also decreased. The annual decrease was faster for the period 2008 to 2014–15 than for the period 1994 to 2004–05, potentially due to the increased funding for Aboriginal and Torres Strait Islander tobacco control since 2008. The proportion of ever smokers who had quit increased among Indigenous adults from 2002 to 2014–15, with faster increases among those living in non-remote areas than in remote areas.14

There appears to have been no change to the ‘gap’ in smoking prevalence between the Aboriginal and Torres Strait Islander adult population and the non-Indigenous adult population during the 20 years to 2014–15, which remained steady at about 30 percentage points. Although there was a slower relative annual decrease in smoking prevalence among the Aboriginal and Torres Strait Islander population (1.0%) compared with the non-Indigenous population (2.7%), the average absolute annual decrease in percentage points (0.3%) was the same for both populations, and there has been substantial progress among Aboriginal and Torres Strait Islander peoples.14 Some have noted the importance of emphasising and maximising this progress, rather than focusing solely on ‘closing the gap’.15

The prevalence of current smoking among the Stolen Generation proxy population declined from about 66% in 2002 to about 50% in 2012-13.10 Compared with those who had not been removed, the Stolen Generations were more likely to be smokers in each of the survey years, with the gaps ranging from 8 to 17 percentage points. Current smoking prevalence among descendants of all people removed has also decreased over time from about 50% in 2004-05 to 42% in 2014-15.10

8.3.3 Geographical variations in smoking rates

While the figures in the above tables provide a broad overview of smoking prevalence among Aboriginal and Torres Strait Islander peoples, it is important to note that patterns of smoking are not uniform throughout Aboriginal and Torres Strait Islander communities. Although smoking prevalence among Indigenous Australians has been declining in both non-remote and remote areas, most of the change has occurred in non-remote areas. The proportion of daily smokers aged 18 years and over in non-remote areas decreased from 48% in 2002 to 35% in 2018–19, while in remote areas, there was a decrease of only one percentage point over the same period, from 50% to 49%.9 Figure 8.3.1 shows the proportion of current daily smokers by remoteness area and Indigenous status.

 

Figure 8.3.2 [SH1]  Age-standardised percentage of current daily smokers aged 18+ by remoteness area and Indigenous status, 2018–19.

Source: National Aboriginal and Torres Strait Islander Health Survey, 2018-19,9 Table 2.3 Australian Bureau of Statistics Table Builder16 , using data from the National Health Survey: First Results, 2017-18,11 Table 6.3

There are also differences in prevalence rates among the states and territories (Figure 8.3.3).

 

Figure 8.3.3 Percentage of current daily smokers, Aboriginal and Torres Strait Islander peoples aged 18+, by state or territory, 2018–19

Source: National Aboriginal and Torres Strait Islander Health Survey, 2018-19, Table 3.39

Note: [SH1] Data for ACT were noted as having a high margin of error and should be used with caution

 

 

There are also variations in prevalence by gender within these jurisdictions. For example, in 2012–13 (National Aboriginal and Torres Strait Islander Health Survey data), daily smoking was more common among Indigenous men living in the Northern Territory (58%) and South Australia (46%) than Indigenous women in these states (44% and 35%, respectively; see ABS Table 24).1

More striking, however, are the variations in smoking behaviour between smaller regions and individual communities. The 2012–13 National Aboriginal and Torres Strait Islander Health Survey examined prevalence of smoking as defined by Aboriginal and Torres Strait Islander Commission region, and found a large variation between regions.1 For example, daily smoking prevalence ranged from 28% in the Australian Capital Territory, to 68% in Katherine. There were also marked gender differences within some regions; prevalence among Indigenous men in West Kimberley was 89%, compared with 48% among Indigenous women in the same region (see ABS Table 23).1 Other regional and community-specific surveys have also demonstrated marked differences. For example, a survey of Aboriginal and Torres Strait Islander women aged 15–34 years in 23 communities in far north Queensland found a smoking prevalence of 62%,17 and studies have confirmed higher levels of smoking in the Top End of the Northern Territory than for the Indigenous population as a whole.18-21 The most recent of these studies found smoking prevalence of 76%20 and 70%21 in Top End communities.

Readers interested in examining earlier regional prevalence surveys are referred in the first instance to the comprehensive literature review by Ivers,22 which provides a summary of research up until 1999.

 

8.3.4 Socio-economic factors

Socio-economic factors are strongly related to smoking behaviour throughout the general Australian population (see Chapter 1, Section 1.7 for further discussion).

Aboriginal and Torres Strait Islander peoples are still significantly more likely than non-Indigenous people to be disadvantaged, in measures such as educational attainment, employment, income, and home ownership. 4, 23 In 2014–15, 61% of Indigenous Australians of working age (15– 64 years) were in the labour force; compared with 77% of non-Indigenous Australians. The proportion of Indigenous Australians of working age who were not in the labour force increased from 36% in 2008 to 39% in 2014–15.24 Indigenous Australians have relatively low average weekly incomes compared with non-Indigenous people and are under-represented in the highest income bracket. In 2014–15, more than one-third (36%) of Indigenous adults were living in households in the lowest income quintile; twice the proportion of non-Indigenous adults (17%).24 Moreover, Aboriginal and Torres Strait Islander peoples are over-represented among those Australians who experience mental illness (as evidenced by self-reported levels of psychological distress, depression, higher rates of hospitalisation for mental illness, and death and injury through suicide and intentional injury), homelessness, and exposure to the criminal justice system as offenders (with imprisonment at 13 times the rate of non-Indigenous people and juvenile detention at 23 times the rate for non-Indigenous youth).25 Each of these factors is associated with a greater likelihood of smoking (see Chapter 1, Section 1.9). The overall higher degree of disadvantage experienced by Aboriginal and Torres Strait Islander peoples is likely to be a major contributor to the high prevalence of smoking.

The prevalence of smoking also varies within the Aboriginal and Torres Strait Islander populations according to socio-economic factors, as they do in the general Australian population. Smoking is more prevalent among Aboriginal and Torres Strait Islander peoples who have less education, are unemployed, are renting rather than owning or buying their own home, and who are in the lower income brackets. 26-28 Table 8.3.3 presents findings for the 2018–19 National Aboriginal and Torres Strait Islander Health Survey, with data for the non-Indigenous population from the 2017–18 National Health Survey included for comparison. When comparing Indigenous and non-Indigenous people of similar socio-economic status, Indigenous peoples have a higher smoking prevalence than for non-Indigenous people.

 

Table 8.3.3 Age-standardised proportion of current daily smoking among Aboriginal and Torres Strait Islander peoples (2018–19) and the non-Indigenous population (2017–18) aged 18 and over by a range of socio-economic indicators

 

Current daily smokers (% rounded)

Age-standardised rate ratio*

 

Indigenous people

Non-Indigenous people

 

Persons aged 18 years and over

40.2

13.8

2.9

Highest year of school completed

Year 12

28.8

13.5

2.1

Year 11

50.6

22.7

2.2

Year 10 or below

50.7

22.1

2.3

Labour force status

 

Employed

34.1

13.2

2.6

Unemployed

53.2

26.9

2

Not in the workforce

51.4

13.5

3.8

*Indigenous to non-Indigenous rate ratios are calculated by dividing the proportion of Indigenous people with a particular characteristic by the proportion of non-Indigenous people with the same characteristic.

Excludes those still attending school.

Source: National Aboriginal and Torres Strait Islander Health Survey 2018–199 and 2017–18 National Health Survey11

Experiencing more than one life stressor (for example, serious illness, death of a family member or friend, divorce, alcohol or drug-related problems, abuse, overcrowding, discrimination or racism) and feeling financial stress in the previous year (defined as lacking the ability for themselves or another household member to access $2000 in an emergency) were also indicators for increased risk of smoking in Indigenous adults in the 2002 and the 2004–05 national Aboriginal and Torres Strait Islander surveys. 27, 28 The 2004–05 survey also reported significant associations between smoking and higher levels of psychological distress or having a disability or other long-term health condition.28 Data from the 2002 National Aboriginal and Torres Strait Islander Social Survey show that Aboriginal and Torres Strait Islander peoples who had been arrested or incarcerated in the last five years were significantly more likely to be smokers; those who reported all four of ‘arrested in last 5 years’, ‘incarcerated in last 5 years’, ‘used legal services in past 12 months’ and ‘victim of violence in past 12 months’ were nearly 10 times more likely to be smokers than those who did not report any of these experiences.27

Although Aboriginal and Torres Strait Islander communities have had different experiences of colonisation, the colonising process has overall had an important influence on ongoing patterns of tobacco use by Aboriginal and Torres Strait Islander peoples (see Section 8.2). Detailed analyses of the 1994 National Aboriginal and Torres Strait Islander Survey and the 2002 National Aboriginal and Torres Strait Islander Social Survey identify removal from family as significantly related to being a smoker.26, 27 After adjusting for age, gender and socio-economic variables, the 2002 Social Survey data showed that Aboriginal and Torres Strait Islander people were twice as likely to be smokers if they had been removed from their natural family.27

There is a significant association between racism and smoking.29 A study of pregnant Indigenous women in Perth reported that stress related to racial discrimination was a factor contributing to their smoking.30

8.3.5 Prevalence of smoking among pregnant women

In 2017, Indigenous mothers accounted for 20.2% of mothers who smoked tobacco at any time during pregnancy, despite accounting for only around 4.5% of mothers who gave birth in 2017. About two in five Indigenous mothers reported smoking during pregnancy—44.3% compared with 11.8% of non-Indigenous mothers. The proportion of Indigenous mothers who smoked during pregnancy decreased from 52% in 2009 to 44% in 2016.31 Approximately 12% of Indigenous mothers quit smoking after 20 weeks of pregnancy in 2017. Rates of smoking during pregnancy were highest for Indigenous mothers living in very remote (55%) and remote areas (48%), while 38% of Indigenous women living in major cities smoked during pregnancy.31

Several local or regional studies have also shown that Indigenous women have a higher prevalence of smoking during pregnancy and after giving birth than non-Indigenous women, with reported smoking prevalence ranging from 41‒67%.32-39 An analysis of the 2007 National Perinatal Data Collection shows that smoking rates for Indigenous mothers was highest for those in outer regional areas (56%) and lowest for those in major cities (49.3%).40

In 2015, one quarter of teenage mothers identified as Aboriginal and/or Torres Strait Islander, while comprising only 5% of the female population in the same age group. Compared to non-Indigenous teenage mothers, Indigenous teenage mothers were 1.5 times as likely to smoke in the first 20 weeks of pregnancy (43% compared with 28%) and 1.7 times as likely to smoke after 20 weeks (36% compared with 21%).41 This trend of higher smoking rates during pregnancy among teenage Indigenous women has also been found in studies in Queensland, South Australia and Western Australia. 34, 42, 43 The South Australian study also reported that the likelihood of smoking heavily (consuming 20 or more cigarettes daily) increased with age, and at all ages except for during their teens, Indigenous women smoked more heavily during pregnancy than non-Indigenous women.42

See Section 8.7.3.5 for health impact of smoking during pregnancy and Section 8.10.13.3 for tobacco action initiatives that address smoking during pregnancy.

8.3.6 Prevalence of smoking among health workers

A range of small surveys44-50 and anecdotal evidence51 suggest that Aboriginal and Torres Strait Islander health workers have a high prevalence of smoking. Findings have ranged between 38% and 51%, 44, 46-48, 50 and about 60–64%.45, 49 One survey, undertaken as part of the National Aboriginal and Torres Strait Islander Tobacco Control Project, found that 39% of health workers who participated in focus groups for the project were smokers. One study observed that this was likely to be an underestimate of actual smoking rates among health workers, since smokers were noticeably less likely to volunteer to participate. 44 Research has found that many Indigenous health workers who smoke, smoke heavily,47 and that tobacco use provides a means of coping with the stressful nature of their workloads. 47, 49 A 2013 study of Aboriginal health workers in South Australia found that the prevalence of current smokers was 50.6%; non-smokers (49.5%) comprised quitters (22.4%) and never smokers (27.1%).50 Surveys of staff of Aboriginal community-controlled health services in 2012–13 found that smoking prevalence among Aboriginal and Torres Strait Islander staff was lower than their general communities, but only modestly lower than among other employed Aboriginal and Torres Strait Islander people.52 These studies indicate a need for appropriate support and education for health workers as well as the communities in which they work. See Section 8.10.5 for further information on the role of Indigenous health workers in tobacco control, and Section 8.13.5 on policy and funding initiatives to support the health workforce in Aboriginal and Torres Strait Islander health.

8.3.7 Prevalence of smoking among prison populations

Smoking rates among prisoners are generally much higher than in the general community,53 and Aboriginal and Torres Strait Islander peoples are significantly overrepresented in the prison population. Between 2006 and 2016, the Indigenous imprisonment rate increased by 53%, and in 2016 the Indigenous imprisonment rate was 13 times the non-Indigenous rate.24 The 2018 Australian Institute of Health and Welfare report on the health of Australia’s prisoners found that Indigenous peoples accounted for 38% of all entrants and were more likely than non-Indigenous people to be current smokers upon entry to prison (80% and 73% respectively).54 Among prisons that allowed for smoking, 77% of Indigenous dischargees, and almost half (48%) of non-Indigenous dischargees said they were current smokers. 54 Of those who intended to smoke upon release, 31% of Indigenous dischargees from prisons that had banned smoking intended to smoke upon release, compared with 54% of Indigenous dischargees from prisons allowing smoking.Non-Indigenous dischargees (49%) were more likely to have decreased their smoking compared with Indigenous dischargees (34%). Forty percent, of Indigenous prison entrants who smoked reported that they would like to quit, down from more than half (54%) in 2015.54 Smoking cessation programs for Indigenous prisoners, and the more recent implementation of total prison smoking bans, are discussed in Section 8.10.13.4. Smoking bans have been or are being implemented in prisons in all Australian states and territories except Western Australia.

 

8.3.8 International comparisons with other Indigenous peoples

International research has shown that Indigenous groups in settler colonial countries use tobacco at significantly higher levels than the dominant population (Table 8.3.4). Notwithstanding the differences between these populations and their specific cultural and historical circumstances, it is likely that these higher prevalence figures also reflect socio-economic disadvantage, and the legacy of colonisation including experiences of marginalisation, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent adoption and adaption of Western habits and practices55

 

Table 8.3.4 Prevalence rates of current smokers for Indigenous and non-Indigenous people in Canada, New Zealand, the United States and Australia

Country

Indigenous people

Non-Indigenous people

Indigenous group

(year of data)

Prevalence

(%)

Ethnic group

(year of data)

Prevalence

(%)

Canada 56, 57

First Nations (North American Indian) 2012

27.2

 

Non-Indigenous (2017)

15

First Nations (North American Indian) Registered or Treaty Indian 2012

27.7

 

First Nations (North American Indian), not a Registered or Treaty Indian 2012

26.4

Inuit 2012

48.7

 

Métis 202

26.4

 

 

New Zealand 58, 59

Māori (2018–2019)

 

35.0

European/Other (2018–19)

 

14.2

Pacific Islanders (2018–2019)

 

24.4

Asian (2016–17)

 

8.2

United States* 60

American Indian/Alaskan Natives (2018)

25.2

Non-Hispanic Blacks (2018)

18.2

Hispanics (2018)

12.3

Asian Americans (2018)

8.2

Non-Hispanic whites (2018)

17.9

Australia †‡ 9

Aboriginal and Torres Strait Islanders (2018–19)

38.4

Non-Indigenous (2018–19)

13.0

* Aged 18 and over

Aged 15 and over

Age standardised. See Table 11.3 in Australian Bureau of Statistics. 4715.0 - National Aboriginal and Torres Strait Islander Health Survey, 2018-19: Smoking. ABS, 2019

 

 

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