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

Last updated: September 2021 Suggested citation: Greenhalgh, EM, Maddox, R, van der Sterren, A, 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; 2021. Available from http://www.tobaccoinaustralia.org.au/chapter-8-aptsi/8-3-prevalence-of-tobacco-use-among-aboriginal-peo

 

As outlined in 8.1 Aboriginal people and Torres Strait Islanders: social disadvantage, health and smoking—an overview, and 8.2 History of tobacco use among Aboriginal peoples and Torres Strait Islanders Aboriginal and Torres Strait Islander peoples are diverse, but have a common experience of colonisation. The mechanics of colonisation have eroded power, social structures and community resources. Evidence indicates that the drivers associated with tobacco use are generally similar for Aboriginal and Torres Strait Islander peoples and non-indigenous peoples, but Aboriginal and Torres Strait Islander peoples are disproportionality exposed to such drivers.¹ For example, socioeconomic status (SES) is strongly linked to smoking,² and the Aboriginal and Torres Strait Islander population overall report lower SES, increasing the risk of tobacco use (see Section 1.7 and Chapter 9). For Aboriginal and Torres Strait Islander peoples, lower SES is an outcome that has impacted over generations through colonisation, including exclusion from the economy, education and health systems, as well as being paid in tobacco issued as rations.³

Tobacco use is widespread among the Aboriginal and Torres Strait Islander population,⁴ although prevalence varies across regions and communities. The first major national study measuring smoking prevalence in the Aboriginal and Torres Strait Islander population was the National Aboriginal and Torres Strait Islander Survey of 1994,⁵ subsequently updated with the National Aboriginal and Torres Strait Islander Social Surveys of 2002, 2008, and 2014–15.^6-8 The National Health Surveys of 1995⁹ and 2001¹⁰ also provide data on smoking rates, and the National Aboriginal and Torres Strait Islander Health Surveys for 2004‒05,¹¹ 2012–13⁴ and 2018–19¹² have been added to this series, expanding on the Aboriginal and Torres Strait Islander components 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, 2014–15⁸ and the National Aboriginal and Torres Strait Islander Health Survey for 2018–19.¹² Data from the National Aboriginal and Torres Strait Islander Social Survey, 2014–15⁸ 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.¹³

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 Aboriginal and Torres Strait Islander peoples living in remote areas and by socioeconomic indicators, as well as among prison populations, the Stolen Generations, pregnant women, health workers, and among First peoples in other countries.

8.3.1 Latest estimates of smoking prevalence

Table 8.3.1 shows the prevalence of daily smoking in 2018 19 by sex and age group. Thirty-eight per cent of the combined Aboriginal and Torres Strait Islander population aged 15 and over were daily smokers (age standardised).¹² 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%).¹²

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 peoples. 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 Aboriginal and Torres Strait Islander men 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%).¹⁵  

See Section 18.3.1 for prevalence of e-cigarette use in the Aboriginal and Torres Strait Islander population

8.3.2 Smoking prevalence over time

There have been progressive decreases in smoking prevalence among Aboriginal and Torres Strait Islander peoples over time. The prevalence of current (i.e., daily + less often) smoking among Aboriginal and Torres Strait Islander peoples 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 2004.¹⁶ 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.^{12, 17} Figure 8.3.1 shows current smoking among Aboriginal and Torres Strait Islander peoples since 1994.

   

 

Between 2004–05 and 2018–19, the prevalence of daily smoking among Aboriginal and Torres Strait Islander peoples 15 years and over decreased by 12.6%, from 50.0% to 37.4%.^{12, 18} Significant declines were observed among both males and females, with significant reductions in current daily smoking since 2004/05 to 2018/19 observed among those aged 18–24 years (14.7% decrease from 50.5% to 35.8%), 25–34 years (10.6% decrease from 54.6% to 44.0%), 35–44 years (8.5% decrease from 55.1% to 46.6%), and 45-54 years (8.7% decrease from 50.5% to 41.8%). No significant changes were identified among daily smokers aged ≥55 years.  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.¹²

Additional encouraging data show that between 1994 and 2014–15, smoking initiation 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 Aboriginal and Torres Strait Islander adults from 2002 to 2014–15, with faster increases among those living in non-remote areas than in remote areas.¹⁷

Between 2004-05 and 2018-2019, there was a 9.8% absolute decline (95%CI 6.5,13.1) in current daily smoking prevalence among the Aboriginal and Torres Strait Islander population, and a 7.5% absolute decline (95%CI 6.6,8.4) among the total adult population. However, the difference was not statistically significant (2.3% difference; 95%CI -1.1,5.7). Given the diverse contexts and ongoing experience of colonisation, the importance of focusing on the progress of declining tobacco prevalence among the Aboriginal and Torres Strait Islander population in relation to Indigenous tobacco control is critically important, as opposed to comparisons to the non-Indigenous population.¹⁸ This assists to foster a safer environment for Aboriginal and Torres Strait Islander peoples’ health to thrive, rather than centering Aboriginal and Torres Strait Islander tobacco prevalence on the non-Indigenous population and focusing on ‘closing the gap’.¹⁸

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 Aboriginal and Torres Strait Islander peoples 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 one percentage point over the same period, from 50% to 49%.¹² Figure 8.3.2 shows the proportion of current daily smokers by remoteness area.

 

 

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

 

Note: 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 sex within these jurisdictions and by remoteness. For example, in 2012–13 (National Aboriginal and Torres Strait Islander Health Survey data), daily smoking was more common among Aboriginal and Torres Strait Islander males living in the Northern Territory (58%) and South Australia (46%) than Aboriginal and Torres Strait Islander females in these states (44% and 35%, respectively; see ABS Table 24).⁴ In addition, while current smoking prevalence in major cities substantially reduced and moderately reduced in regional areas for both males and females between 1994 and 2018/9, in remote areas the prevalence increased for females and did not significantly change for males.¹⁹

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.⁴ 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 Aboriginal and Torres Strait Islander men in West Kimberley was 89%, compared with 48% among Aboriginal and Torres Strait Islander women in the same region (see ABS Table 23). ⁴ 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%,²⁰ and studies have confirmed higher levels of smoking in the Top End of the Northern Territory than for the Indigenous population as a whole.^21-24 The most recent of these studies found smoking prevalence of 76%²³ and 70%²⁴ 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,²⁵ which provides a summary of research up until 1999 and Thurber et al up until 2020.¹⁹

8.3.4 Socio-economic factors

Socio-economic factors such as educational attainment, employment, and income are strongly related to smoking behaviour (see Section 1.7 and Chapter 9). In 2018–19, 49% (243,800) of Aboriginal and Torres Strait Islander peoples of working age (15– 64 years) were in the labour force; however, the proportion who were not in the labour force increased from 36% in 2008 to 51.4% in 2018–19,²⁶ and more than one-third (37%) of Aboriginal and Torres Strait Islander adults were living in households in the lowest income quintile.²⁷ Further, almost a quarter of Aboriginal and Torres Strait Islander peoples reported having a diagnosed mental health or behavioural condition.²⁷ Aboriginal and Torres Strait Islander peoples also reported experiences of 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.²⁸

For many Aboriginal and Torres Strait Islander peoples, positive mental health and wellbeing is commonly indicated by a number of factors. This includes, but is not limited to a sense of belonging, strong cultural identity, positive relationships, and feeling that life has purpose and value.^{29, 30} In contrast, major stressors such as removal from family, incarceration, death of a close friend or family member, discrimination and unemployment, and everyday life stressors can impact and result in poor mental health outcomes.^{31, 32}

The ongoing experience and mechanisms of colonisation as outlined above (see also 8.1 and 8.2), directly and indirectly impacts mental health and wellbeing, including trauma experiences. Dispossession from land, forced removal of children from families, and institutionalised racism have enduring legacies on social and emotional wellbeing.²⁹ Experiences of discrimination have been strongly associated with social and emotional wellbeing outcomes. Among Aboriginal and Torres Strait Islander peoples experiencing moderate-high discrimination, it was three to four times as common to experience low life satisfaction and low happiness compared to those not reporting experiences of discrimination.³³ Further, prevalence was approximately double for other social and emotional wellbeing-related outcomes: psychological distress, pain, and doctor-diagnosed anxiety and depression compared to those not experiencing discrimination. Aboriginal and Torres Strait Islander peoples experiencing moderate-high levels of discrimination were associated with current smoking status, with smoking more than twice as common among Aboriginal and Torres Strait Islander peoples experiencing moderate-high levels of discrimination, compared to no discrimination (PR=2.21;1.99,2.46) ³³ and there is a significant association between racism and smoking.³⁴ A study of pregnant Aboriginal and Torres Strait Islander women in Perth also reported that stress related to racial discrimination was a factor contributing to their smoking.³⁵

The abovementioned factors are associated with a greater likelihood of smoking (see Chapter 9).

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.^{3, 36, 37} Table 8.3.2 presents findings for the 2018–19 National Aboriginal and Torres Strait Islander Health Survey.

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 Aboriginal and Torres Strait Islander adults in the 2002 and the 2004–05 national Aboriginal and Torres Strait Islander Health surveys.^{3, 37} 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.³⁷

8.3.5 Prevalence of smoking among prison populations

Smoking rates among prisoners are generally much higher than in the general community,³⁸ and Aboriginal and Torres Strait Islander peoples are significantly overrepresented in the prison population. Between 2006 and 2019, the Aboriginal and Torres Strait Islander imprisonment rate increased by 61%, and in 2019 the Aboriginal and Torres Strait Islander imprisonment rate was 12 times the non-Indigenous rate.²⁶ 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.³

The 2018 Australian Institute of Health and Welfare report on the health of Australia’s prisoners found that Aboriginal and Torres Strait Islander peoples accounted for 38% of all entrants, 80% of whom were current smokers upon entry to prison.³⁹ Among prisons that allowed smoking, 77% of Aboriginal and Torres Strait Islander dischargees said they were current smokers.³⁹ Of those who intended to smoke upon release, 31% of Aboriginal and Torres Strait Islander dischargees from prisons that had banned smoking intended to smoke upon release, compared with 54% of those from prisons allowing smoking. Thirty-four per cent of Aboriginal and Torres Strait Islander discharges reported having decreased their smoking. Forty percent of Aboriginal and Torres Strait Islander prison entrants who smoked reported that they would like to quit, down from more than half (54%) in 2015.³⁹ Smoking cessation programs for Aboriginal and Torres Strait Islander 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 and the ACT.

8.3.6 Smoking among the Stolen Generations

Aboriginal and Torres Strait Islander peoples and communities have a range of different experiences of colonisation. However, colonisation has impacted ongoing patterns of tobacco use among 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.^{3, 36} 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 family.³

In 2014–15, 50% of the Stolen Generations proxy population reported being current smokers, compared with 40% who were not removed (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). 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%).¹³ The prevalence of current smoking among the Stolen Generation proxy population declined from about 66% in 2002 to about 50% in 2012-13.¹³ 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 2014-15.¹³

8.3.7 Prevalence of smoking among pregnant women

About two in five (43%) Aboriginal and Torres Strait Islander women reported smoking during pregnancy in 2019. The proportion of Aboriginal and Torres Strait Islander women who smoked during pregnancy decreased from 50% in 2009 to 43% in 2019.⁴⁰ Approximately 10% of Aboriginal and Torres Strait Islander women quit smoking after 20 weeks of pregnancy in 2019. Rates of smoking during pregnancy were highest for Aboriginal and Torres Strait Islander women living in very remote (55%) and remote areas (48%), while 38% of those living in major cities smoked during pregnancy.⁴⁰

Several local or regional studies have also shown that a relatively high proportion of Aboriginal and Torres Strait Islander women smoke during pregnancy and after giving birth, with reported smoking prevalence ranging from 41‒67%.^{41-48 49}

In 2015, 43% of Aboriginal and Torres Strait Islander pregnant teenagers smoked in the first half of pregnancy, and 36% smoked in the second half.⁵⁰ This trend of higher smoking rates during pregnancy among Aboriginal and Torres Strait Islander teenagers has also been found in studies in Queensland, South Australia and Western Australia.^{43, 51, 52} The South Australian study also reported that the likelihood of smoking heavily (consuming 20 or more cigarettes daily) increased with age.⁵¹

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.

8.3.8 Prevalence of smoking among health workers

A range of small surveys^53-59 and anecdotal evidence⁶⁰ suggest that smoking prevalence ranges between 38% and 51%,^{53, 55-57, 59} and about 60–64%^{54, 58} among Aboriginal and Torres Strait Islander health workers. 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.⁵³ 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%).⁵⁹ 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, and lower than among other employed Aboriginal and Torres Strait Islander peoples.⁶¹ 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 Aboriginal and Torres Strait Islander 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.

8.3.9 International comparisons with other First peoples

Indigenous peoples across Australia and around the world are diverse. However, the health status and needs of Indigenous peoples in Australia, Aotearoa New Zealand, Canada and the United States of America are often compared due to the shared experience of colonisation. One enduring impact has been a disproportionately high prevalence of commercialⁱ tobacco use ( Table 8.3.3) compared with their non-Indigenous counterparts. Notwithstanding the differences across and between these populations and their specific cultural and historical circumstances, commercial tobacco prevalence reflects the legacy of colonisation, including experiences of marginalisation, socio-economic disadvantage, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent adoption and adaption of Western habits and practices.⁶²

 

i  Commercial tobacco is produced for recreational use using processed leaf and chemical additives, in stark contrast to ceremonial tobacco used in cultural practices, i.e. – the use of sacred medicinal tobacco which is used more commonly across parts of Turtle Island (North America).

 

Relevant news and research

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