|Last updated: August 2016
Suggested citation: van der Sterren, A, Greenhalgh, EM, Knoche, D, & Winstanley, MH 8.6 Smoking cessation and Aboriginal peoples and Torres Strait Islanders. In Scollo, MM and Winstanley, MH [editors].Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/8-6-cessation
The most recent informationi on smoker status (including information on ex-smokers and never smokers) is reported in the 2012–13 National Aboriginal and Torres Strait Islander Health Survey.1 These prevalence rates, adjusted for age so that they are comparable to the non-Indigenous population, are reported in Figure 8.6.1. Further analyses of smoking status data by age, sex, and Indigenous status are shown in Figure 8.6.2.
Age-standardised smoker status, Indigenous and non-Indigenous persons 15 years and over, 2012–13
*Current smoker includes daily, weekly and other current smokers
Source: ABS 20141 using data from the National Aboriginal and Torres Strait Islander Health Survey 2012–13 and the 2011–12 Australian Health Survey
In 2012–13, from ages 25–34 and older, Indigenous males were significantly less likely to be ex-smokers than non-Indigenous males. For women, there was only a significant difference in ex-smokers among those aged 35–44. These patterns are shown in Figure 8.6.2.
Proportion of ex-smokers by Indigenous status, sex, and age, 2012–13
Source: ABS 20141 using data from the National Aboriginal and Torres Strait Islander Health Survey 2012–13 and the 2011–12 Australian Health Survey
In 2012–13, a nationally representative sample of 2522 Aboriginal and Torres Strait Islander people from 35 locations across Australia were interviewed, which formed the baseline data for the Talking About The Smokes (TATS) Project. The TATS project aimed to provide a comprehensive evidence base for guiding practice and policy to reduce tobacco-related harm among Indigenous Australians. Questions regarding past quit attempts revealed that compared with the general population, fewer Aboriginal and Torres Strait Islander daily smokers had ever tried to quit, but a similar proportion had attempted to quit within the past year (Figure 8.6.3). Of those who had tried to quit in the past year, similar proportions reported sustaining their most recent quit attempt for one month or more (Indigenous, 31% v non-Indigenous, 33%) and six months or more (Indigenous, 10% v non-Indigenous, 11.7%).2
Comparison of tobacco-related behaviour modification among Aboriginal peoples and Torres Strait Islanders (daily smokers) and the general Australian population (daily smokers)
Source: Nicholson et al. (2015)2 using data from the Talking About The Smokes (TATS) Project and the Australian International Tobacco Control Policy Evaluation Project (ITC Project).
Reasons for quitting
A consistent theme in many studies of Indigenous smokers is the roles of families and communities in motivating cessation. In the TATS project, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, and having support from friends and family were associated with wanting to quit.3 A 2010 national study investigating Indigenous smoking issues found that key motivators for smoking cessation were: the importance of family and kin, and the impact of smoking on them; supporting self-efficacy in the quitting process; the cost of smoking, particularly because it affects the family; and the adverse effects of smoking on sport and physical activity.4 Similarly, a qualitative study in 2008 found that the health and wellbeing of Indigenous people’s families was particularly important in motivating quit attempts; smokers cited protecting their children and family from the health consequences of secondhand smoke, acting as positive role models to their children, reducing the negative social and economic impacts that smoking was having on their family, and maintaining good health to fulfil their family responsibilities as reasons to quit smoking.5
Health concerns are also important determinants of cessation among Indigenous Australians. Participants in the TATS project cited worrying about future smoking-related health effects and believing quitting to be beneficial as reasons for wanting to quit.3 The National Aboriginal and Torres Strait Islander Tobacco Control Project (2001) found that among those who had successfully quit smoking, a main motivator was either suffering an illness or being diagnosed with a serious illness. Other reasons for quitting included wanting to live long enough to see their grandchildren grow up, a personal wish to quit, seeing others suffer sickness or dying from tobacco-related illnesses, the cost of tobacco, and their children asking them to give up. Quitters were more likely to have quit at a relatively early age (25 or younger). Half of quitters had done so ‘cold turkey’.6 Western Australian research on the smoking habits of urban Indigenous woman found that of those who had quit smoking, health concerns were cited as the main reason (49%), followed by pregnancy (12%).7 Similarly, motivators for quitting among a group of young urban Aboriginal South Australians included pregnancy and/or children and health reasons, as well as cost issues and sporting performance (for males).8
Barriers to quitting
Research in 1999 evaluating the National Tobacco Campaign (1997–98) found that quitting was perceived as a very difficult goal among Indigenous people in Victoria, and the combination of smoking being strongly embedded in community norms, peer expectation to smoke, and the concomitant lack of social support for quitting discouraged quitting (see Section 8.9.1).9 Recent research has also found that perceiving quitting as very difficult is associated with being less likely to want to quit, as is enjoying smoking.3 Along with being an important motivator for quitting, families can also play a central role in initiation to smoking and maintaining the habit (see Section 8.9).5 In the National Aboriginal and Torres Strait Islander Tobacco Control Project (2001), the reasons most commonly given for returning to smoking after an attempt at quitting were succumbing to peer or family influences, stress, and addiction.6 The authors of a Western Australian study highlight that one of the key functions of smoking among urban Indigenous women is its role as a facilitator of friendship bonding and social cohesiveness. This strongly reinforces smoking behaviour and perceptions, and undermines likelihood of quitting, since to give up smoking is to risk social isolation and alienation.7
Barriers to quitting among pregnant women
Smoking by Aboriginal and Torres Strait Islander women during pregnancy remains high (see Section 8.3), and several studies have investigated smoking behaviours in this group. In 2012, 11.6% of Aboriginal and Torres Strait Islander women who smoked during the first 20 weeks of pregnancy reported not smoking during the second 20 weeks of pregnancy, which was half that of non-Indigenous women (22.9%).10 Between 2005 and 2011, there was a statistically significant decline (of 6%) in smoking during pregnancy among Indigenous women, but this drop was much greater among non-Indigenous women (25%).11
Studies have found that women may report cutting down the number of cigarettes smoked in an attempt to limit risk to their baby.12,13 In a New South Wales study, 24% of women using tobacco at the beginning of their pregnancy quit, while about 51% decreased their tobacco use (13% stayed the same, and 12% increased their use).14 Among those who quit, a significant proportion may take up smoking again after the birth of the baby.13,15 A qualitative study in 2013 found that Indigenous women in NSW were aware of the dangers of smoking, felt guilty about smoking while pregnant, and tried to change their smoking behaviour, with many contemplating quitting; however, due to the difficulty of quitting, reducing consumption was more common.16 There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight17 and reduce preterm birth.18 However, Australian19 and UK20 guidelines state that health professionals should be recommending complete abstinence to pregnant women in order to maximise health benefits.
Two studies have found that pregnant Indigenous women may be more motivated and able to quit than smokers generally due to their status as mothers-to-be.21,22 Both studies found that nicotine dependence was generally low. One of the studies21 also involved investigating the ‘stages of change’ profiles of their participants, and found that 14% had taken action to give up (‘action’ stage), 55% were thinking about giving up (‘contemplation’ stage), and 31% were not thinking about giving up (‘pre-contemplation’ stage). Importantly, 45% of women had both low nicotine dependency and were thinking about giving up (‘contemplation’). The mean number of previous quit attempts for this sample was 1.4, with 15% having tried to quit more than 10 times.
Apart from the physical addiction, the barriers to quitting reported by pregnant women include: family pressure to continue smoking; using smoking as a way to manage difficult life circumstances and the related stressors (which were seen to increase during pregnancy); and the perceived social benefits of smoking, as an opportunity for ‘yarning’, relaxation and time out.12,13 Participants in the qualitative NSW study suggested that pregnant women might risk social isolation by quitting, as smoking plays such an important role in social cohesion. These findings might also help explain the higher likelihood of cutting down rather than quitting; this strategy allows Aboriginal pregnant women to feel socially connected, while also trying to minimise harm to their foetus.16 Indigenous women are also more likely to smoke during pregnancy if there are more smokers in the household,15,23 if they have a partner who smokes,23 and if they experience higher levels of daily stress.23 Tobacco action initiatives for pregnant Indigenous women are discussed in Section 22.214.171.124.
Barriers to quitting among health workers
Studies on tobacco use among Aboriginal health workers have found that the majority of Aboriginal health workers wanted to quit, and/or had made at least one quit attempt in the recent past.6,24-26 A 2013 study of Aboriginal health workers in South Australia found that among current smokers (just over half the total sample), half had tried to quit in the past year, and over two-thirds demonstrated a readiness to quit. Successful quitters (about one quarter of the total sample) had the highest levels of perceived social support and part-time employment. Current smokers expressed lower emotional wellbeing compared with quitters and never smokers, and three times as many lived with another smoker.27 The TATS study found that staff of Aboriginal community-controlled health services who were smokers were more likely than smokers in their communities to have ever tried to quit, to have often noticed antismoking advertising, and to have used stop smoking medications, often with the support of their workplace. Ex-smokers were most likely to report being confident in talking to others about smoking and quitting. About three-quarters of smokers agreed that being a non-smoker sets a good example to patients, and most did not smoke with, or in front of, patients.28
Relieving stress, particularly stress associated with the job, is commonly cited as a reason for Aboriginal health workers to smoke.6,26-29 In a qualitative study in 2012, Aboriginal Health Workers described burdensome stress and grief as leaving them unable to prioritise quitting smoking. (However, smoking appears to increase stress, while quitting is associated with reduced stress—see Section 7.12.3). More broadly, the normalisation of smoking in Indigenous communities was an overarching barrier to cessation; smoking was often part of the workplace culture, and there were a lack of smokefree places and policies.30 Other barriers that have been reported are a lack of support, living/working in environments where smoking is common, having a partner who smokes, addiction, and withdrawal when trying to quit.26 Smoking among Aboriginal health workers may affect their capacity to deliver smoking cessation activities (see Section 8.10.5). Specific tobacco action programs targeting Aboriginal health workers are discussed in Section 126.96.36.199.
Smoking cessation behaviour among young Aboriginal and Torres Strait Islanders is discussed in Section 8.4. Attitudes and beliefs about smoking are discussed further in Section 8.9, and initiatives and policies designed to promote and support quitting among Aboriginal peoples and Torres Straits Islanders are discussed in sections 8.10 and 8.13 respectively. Smoking cessation is discussed in greater detail in Chapter 7.
1. Australian Bureau of Statistics. 4727.0.55.006 - Australian Aboriginal and Torres Strait Islander health survey: Updated results, 2012–13. 2014. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4727.0.55.0062012%E2%80%9313?OpenDocument
2. Nicholson A, Borland R, Davey M, Stevens M, and Thomas D. Past quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 2015; 202(10):S20–5. Available from: http://europepmc.org/abstract/med/26017251
3. Nicholson A, Borland R, Davey M, Stevens M, and Thomas D. Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers. Medical Journal of Australia, 2015; 202(10):S26–32. Available from: http://europepmc.org/abstract/med/26017252
4. 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 Social Research Institute and Winangali; 2010. Available from: http://www.health.gov.au/internet/ctg/Publishing.nsf/Content/home-1/$file/Smoking%20Campaigns%20report.pdf
5. Johnston V and Thomas D. Smoking behaviours in a remote Australian Indigenous community: The influence of family and other factors. Social Science & Medicine, 2008; 67(11):1708–16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18938006
6. Lindorff KJ. Tobacco time for action: National Aboriginal and Torres Strait Islander tobacco control project final report. Canberra, Australia: National Aboriginal Community Controlled Organisations, 2002.
7. Gilchrist D. Smoking prevalence among Aboriginal women. Aboriginal and Islander Health Worker Journal, 1998; 22(4):4–6. Available from: http://search.informit.com.au/documentSummary;dn=215154326331601;res=IELIND
8. Cosh S, Hawkins K, Skaczkowski G, Copley D, and Bowden J. Tobacco use among urban Aboriginal Australian young people: A qualitative study of reasons for smoking, barriers to cessation and motivators for smoking cessation. Australian Journal of Primary Health, 2015; 21(3):334–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24980459
9. Murphy M and Mee V. Chapter 6: The impact of the national tobacco campaign on Indigenous communities: A study in Victoria, in Australia's national tobacco campaign: Evaluation report vol.1. Hassard K, Editor Canberra: Department of Health and Aged Care; 1999. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-publicat-document-metadata-tobccamp.htm/$FILE/tobccamp_g.pdf
10. Hilder L, Zhichao Z, Parker M, Jahan S, and Chambers GM. Australia’s mothers and babies 2012. Perinatal statistics series no. 30. Cat. no. PER 69, Canberra: AIHW, 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550033
11. Australian Institute of Health and Welfare, Birthweight of babies born to Indigenous mothers. Cat. no. IHW 138. Canberra: AIHW; 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129548202
12. Wood L, France K, Hunt K, Eades S, and Slack-Smith L. Indigenous women and smoking during pregnancy: Knowledge, cultural contexts and barriers to cessation. Social Science & Medicine, 2008; 66:2378–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18313186
13. Passey M, Gale J, Holt B, Leatherday C, Roberts C, et al., Stop smoking in its tracks: Understanding smoking by rural Aboriginal women. The 10th national rural health conference, ed. Gregory G. Canberra: National Rural Health Alliance; 2009. Available from: http://10thnrhc.ruralhealth.org.au/papers/docs/Passey_Megan_D9.pdf
14. Passey M, Gale J, Stirling J, and Sanson-Fisher R, Tobacco, cannabis and alcohol: Changes in pregnancy among Aboriginal women in NSW. Primary health care research conference Adelaide: Flinders University Primary Health Care Research & Information Service; 2010. Available from: http://www.phcris.org.au/download.php?id=6874&spi=3
15. Johnston V, Thomas D, McDonnell J, and Andrews R. Maternal smoking and smoking in the household during pregnancy and postpartum: Findings from an Indigenous cohort in the Northern Territory. Medical Journal of Australia, 2011; 194(10):556–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21644912
16. Gould GS, Munn J, Avuri S, Hoff S, Cadet-James Y, et al. “Nobody smokes in the house if there's a new baby in it”: Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia. Women and Birth, 2013; 26(4):246–53. Available from: http://dx.doi.org/10.1016/j.wombi.2013.08.006
17. England LJ, Kendrick JS, Wilson HG, Merritt RK, Gargiullo PM, et al. Effects of smoking reduction during pregnancy on the birth weight of term infants. American Journal of Epidemiology, 2001; 154(8):694–701. Available from: www.ncbi.nlm.nih.gov/pubmed/11590081
18. Seybold D, Broce M, Siegel E, Findley J, and Calhoun B. Smoking in pregnancy in West Virginia: Does cessation/reduction improve perinatal outcomes? Maternal and Child Health Journal, 2012; 16(1):133–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21258963
19. The Royal Australian College of General Practitioners, Supporting smoking cessation: A guide for health professionals. Melbourne: RACGP; 2014. Available from: http://www.racgp.org.au/your-practice/guidelines/smoking-cessation
20. National Institute for Healthcare and Excellence (NICE). Quitting smoking in pregnancy and following childbirth. Public health guidance 26. 2010. Available from: http://www.nice.org.uk/guidance/ph26
21. Heath D, Panaretto K, Manessis V, Larkins S, Malouf P, et al. Factors to consider in smoking interventions for Indigenous women. Australian Journal of Primary Health, 2006; 12(2):131–5. Available from: http://www.publish.csiro.au/paper/PY06032.htm
22. Panaretto K, Mitchell M, Anderson L, Gilligan C, Buettner P, et al. Tobacco use and measuring nicotine dependence among urban Indigenous pregnant women. Medical Journal of Australia, 2009; 191(10):554–7. Available from: http://www.mja.com.au/public/issues/191_10_161109/pan10395_fm.html
23. Gilligan C, Sanson-Fisher R, D'Este C, Eades S, and Wenitong M. Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women. Medical Journal of Australia, 2009; 190(10):557–61. Available from: http://www.mja.com.au/public/issues/190_10_180509/gil10102_fm.html
24. Andrews B, Oates F, and Naden P. Smoking among Aboriginal health workers: Findings of a 1995 survey in western New South Wales. Australian and New Zealand Journal of Public Health, 1997; 21:789–90. Available from:
25. West L, Young D, and Lloyd J. A report on far north Queensland Aboriginal and Torres Strait Islander health workers. Knowledge, attitudes and beliefs about smoking cessation and prevention. Cairns: Queensland Health, 1998.
26. Mark A, McLeod I, Booker J, and Ardler C. Aboriginal health worker smoking: A barrier to lower community smoking rates? Aboriginal and Islander Health Worker Journal, 2005; 29(5):22–6. Available from: http://search.informit.com.au/documentSummary;dn=132032641548770;res=E-LIBRARY
27. Maksimovic L, Paquet C, Daniel M, Stewart H, Chong A, et al. Characterising the smoking status and quit smoking behaviour of Aboriginal health workers in South Australia. International Journal of Environmental Research and Public Health, 2013; 10(12):7193–206. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24351741
28. Thomas DP, Davey ME, Panaretto KS, Hunt JM, Stevens M, et al. Smoking among a national sample of Aboriginal and Torres Strait Islander health service staff. Medical Journal of Australia, 2015; 202(10):S85–9. Available from: http://europepmc.org/abstract/MED/26017264
29. Kerdel K and Brice G. Exploring the smokescreen—reducing the stress: Action research on tobacco with Aboriginal primary health care workers in Adelaide. Adelaide: Aboriginal Health Council of South Australia, 2001.
30. Dawson AP, Cargo M, Stewart H, Chong A, and Daniel M. Aboriginal health workers experience multilevel barriers to quitting smoking: A qualitative study. International Journal for Equity in Health, 2012; 11:27. Available from: http://www.biomedcentral.com/content/pdf/1475-9276-11-27.pdf