8.6 Smoking cessation and Aboriginal and Torres Strait Islander peoples

8.6.1 Prevalence of ex-smokers, quit proportions

Table 8.6.1 shows an increase in both the percentage of ex-smokers and percentage of never smokers since 2004–05. This suggests that both increases in the number of people quitting (ex-smokers) and the number of people not taking up smoking in the first place (‘never smokers’) have contributed to the reduction in smoking prevalence (‘current smokers’). However, it should be noted that the mortality among older generations, among whom smoking prevalence may differ to younger generations, could also be contributing to the changes in the proportion of never smokers, ex-smokers and current smokers over time.

The quit proportion, indicated in the final column of Table 8.6.1, highlights the percentage of individuals who have successfully quit smoking among ever smokers. In 2018–19, 36% of Aboriginal and Torres Strait Islander people aged 18 and above, who had previously smoked, had successfully quit. This proportion is 30% higher than it was in 2004–05. ¹

8.6.2 Quit intentions, quit attempts and success in quitting

Quit rates in the population are a function of the percentage of smokers who make an attempt to quit, and the proportions of those attempts that are successful. ³

In 2018–19, the National Aboriginal and Torres Strait Islander Health Survey reported that just over half (51%) of Aboriginal and Torres Strait Islander people aged 15 years and over who currently smoked had made a quit attempt in the past 12 months. ¹

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 and quit intentions revealed that more than two thirds of Aboriginal and Torres Strait Islander daily smokers wanted to quit (70%), a similar proportion had ever tried to quit (69%) and just under half (48%) had attempted to quit within the past year. Of those who had tried to quit in the past year, just under a third (31%) reported sustaining their most recent quit attempt for one month or more, and one in ten (10%) reported sustaining their quit attempt for six months or more. ^{4 , 5}

8.6.3 Use of smoking cessation medications and other supports

The 2012–13 study reported that 39% of daily smokers had ever used nicotine replacement therapy (NRT) or smoking cessation medications with 24% having used them in the past year. Among all smokers and recent ex-smokers in the study, nicotine patches were the most commonly used (24% had ever-used), followed by varenicline (11%), nicotine gum (10%), lozenges (3%), inhalers (3%) and bupropion (1%). ⁶

 In 2020, the Which Way? project conducted a national cross-sectional survey involving 428 Aboriginal and Torres Strait Islander women aged 16-49 years who were either smokers or ex-smokers. The findings revealed that approximately 35.7% of the participants reported having used nicotine replacement therapy (NRT) or smoking cessation medications at some point. The use of NRT and smoking cessation medications was more prevalent among women residing in urban areas, older women, and those who felt more confident discussing quitting with their doctor. Barriers to utilising pharmacological supports reported by participants included concerns about side effects, financial costs and preferences to quit unaided or without help. ⁷

The National Aboriginal and Torres Strait Islander Tobacco Control Project (2001) found that among participants who had successfully quit smoking, half had done so ‘cold turkey’. ⁸

8.6.4 Reasons for quitting

A recurring theme in numerous studies is the significant role of families and communities in motivating smoking 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. ⁵ Further analysis revealed that setting an example to children was one of the most common reasons for thinking about quitting, and making and sustaining a quit attempt among TATS participants. ⁹ A national study conducted in 2010 investigating Indigenous smoking issues identified  key motivators for smoking cessation, including the importance of family and kin, 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. ¹⁰ 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. ¹¹

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. ⁵ Health concerns and the cost of cigarettes were also commonly cited as reason for contemplating quitting, and making and sustaining quit attempts. ⁹ The National Aboriginal and Torres Strait Islander Tobacco Control Project (2001) found that among those who had successfully quit smoking, a primary 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). ⁸ 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%). ¹² 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). ¹³ Attitudes and beliefs about smoking are discussed further in Section 8.9.

8.6.5 Factors that influence 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 cessation efforts (see Section 8.9.1). ¹⁴ 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). ¹¹ A study conducted in Western Australia emphasized that smoking among urban Indigenous women serves as a means to foster friendship bonding and social cohesion. This strong association reinforces smoking behaviour and perceptions while undermining the likelihood of quitting, as quitting smoking risks social isolation and alienation. ¹² Research has also found that perceiving quitting as very difficult is associated with being less likely to want to quit, as is enjoying smoking. ⁵

In the National Aboriginal and Torres Strait Islander Tobacco Control Project (2001), the reasons most commonly cited reasons for relapsing after a quit attempt were succumbing to peer or family influences, stress, and addiction. ⁸ However, stress may not necessarily be a barrier to quitting. Analysis of data from TATS project revealed that more smokers who reported negative life satisfaction, feeling depressed and higher stress at baseline made a quit attempt in the next year. Of those who attempted to quit, individuals who made a quit attempt, those that reported higher stress made more sustained quit attempts (at least one month). ¹⁵

A study examining quitting amongst Aboriginal and Torres Strait Islander smokers living in remote areas found that different factors were associated with making a quit attempt versus sustaining a quit attempt. Younger age, stress, financial deprivation resulting from smoking, pro-quit motivations/attitudes, having a smokefree home, and encouragement from a health professional, family or friends were all associated with a greater likelihood of making a quit attempt. On the other hand, lower nicotine dependence, greater social advantage, chewing pituri, the absence of smoking-induced deprivation and having a smokefree home were associated with having sustained the quit attempt at the 1-month follow-up. ¹⁶

An analysis of the TATS project also found that encouragement from a health professional and motivational attitudes were associated with making a quit attempt. Additionally, previous quit attempts, recent quit attempts, and awareness of tobacco control advertising were linked to making a quit attempt. Sustained quit attempts were associated with longer previous quit attempts, non-daily smoking, and higher quit self-efficacy. ⁹

Initiatives and policies aimed at promoting and supporting quitting among Aboriginal peoples and Torres Straits Islanders are discussed in Sections 8.10 and 8.13, respectively.

8.6.6 Cessation and priority groups

8.6.6.1 Pregnant women

The prevalence of smoking among Aboriginal and Torres Strait Islander women during pregnancy is high (see Section 8.3.7). However, Aboriginal and Torres Strait Islander women are strongly motivated to prevent tobacco-related harms to their babies. A survey of women who had made pregnancy-related quit attempts revealed that they had varied quitting experiences; some were able to quit completely, some reduced consumption and others struggled to quit due to high levels of stress. ¹⁷ In 2020, approximately 13% of Aboriginal and Torres Strait Islander women who smoked reported quitting after 20 weeks of pregnancy. ¹⁸ Among those who quit, a significant proportion may take up smoking again after the birth of the baby. ^{19, 20}  

Studies have found that women often report cutting down the number of cigarettes smoked in an attempt to limit risk to their baby. ^{19, 21} 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). ²² 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. ²³ There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight ²⁴ and reduce preterm birth. ²⁵ However, Australian guidelines state that women who are pregnant should be encouraged to stop smoking completely as any level of exposure to tobacco smoke increases the adverse effects to the expectant mother, fetus and pregnancy. ²⁷ Moreover, the Which Way? project found that women who quit suddenly are more likely to sustain abstinence than those who cut down gradually. ²⁹ 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. ^{30, 31} Research investigating the ‘stages of change’ profiles of their participants, and found that 14% had taken action to give up (the ‘action’ stage), 55% were thinking about giving up (the ‘contemplation’ stage), and 31% were not thinking about giving up (the ‘pre-contemplation’ stage). Notably, 45% of women exhibited both low nicotine dependency and contemplation about quitting. ³⁰

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. ^{19, 21} Participants in the qualitative NSW study suggested that quitting smoking might lead to social isolation, as smoking plays a role in social cohesion within communities. 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 baby. ²³ Indigenous women are also more likely to smoke during pregnancy if there are more smokers in the household, ^{20, 32} if they have a partner who smokes, ³² and if they experience higher levels of daily stress. ³²

Family and community can also play an important role in helping pregnant women quit smoking. A 2019 review identified that across studies of cessation among pregnant Aboriginal and Torres Islander women, social support from family (particularly mothers), partners and Aboriginal elders and aunties was a common facilitator of quitting. Several studies also found that information and advice about the harms of smoking from health professionals or family and friends also facilitated changes in smoking behaviour. ³³ In qualitative research, Aboriginal women indicated that to quit smoking and remain abstinent during pregnancy and post-partum they used a combination of coping strategies. These strategies included replacing smoking with alternative activities such as spending more time with children or engaging in artistic pursuits, keeping busy, avoiding smoking environments, and seeking support from friends and family. ³⁴

The Which Way? project conducted in 2020 found that Aboriginal and Torres Strait Islander women of reproductive age preferred smoking cessation support programs that were holistic and group-based. In particular, women with higher nicotine dependency showed a greater belief in the potential efficacy of group-based cessation programs. Participants also expressed a preference for cessation support to be provided by Aboriginal health workers and face-to-face at an Aboriginal health service. While face-to-face support preferred by most participants, there was also significant interest among some in utilizing phone support and online resources for smoking cessation. ²⁹

However, lack of cessation support and information provided by healthcare professionals was also a recurring theme across studies. Low rates of support provision often stemmed from the belief that advice would be ineffective or that addressing the issue may discourage women from seeking antenatal care. Additionally, a significant proportion of health professionals lacked confidence in discussing the health effects of smoking or initiating discussions about smoking with their clients. ³³

A survey of Aboriginal and Torres Strait Islander women who made quit attempt for pregnancy-related reasons found that using Aboriginal health services was associated with higher odds of a having a smoke-free pregnancy. ¹⁷ However despite often being a first point of contact and important aid for individuals trying to quit, less than half (48.4%) of Aboriginal health workers and practitioners felt they were best positioned to support Aboriginal and Torres Strait Islander women to quit during pregnancy. Lack of time and resources were commonly reported barriers to providing smoking cessation interventions as part of care. ^{17, 35} For a more detailed discussion of the role of Aboriginal health workers in smoking cessation, please refer to Section 8.15.2

Tobacco action initiatives for pregnant Indigenous women are discussed in Section 8.10.6.3.

8.6.6.2 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. ^{8, 36-38} 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. Those who had successfully quit smoking (approximately one quarter of the total sample) had higher levels of perceived social support and were more likely to be employed part-time. Comparatively, current smokers exhibited lower emotional wellbeing when compared to quitters and never smokers, and a greater number of number of them  lived with another smoker. ³⁹ 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. ⁴⁰

Relieving stress, particularly stress associated with the job, is commonly cited as a reason for Aboriginal health workers to smoke. ^{8, 38, 41} In a qualitative study in 2012, Aboriginal Health Workers described burdensome stress and grief as leaving them unable to prioritise quitting smoking. However, it is worth noting that smoking appears to increase stress, while quitting is associated with reduced stress (see Section 9A.3.3). 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. ⁴² Other reported barriers include a lack of support, living/working in environments where smoking is common, having a partner who smokes, addiction, and withdrawal symptoms when trying to quit. ³⁸ Further, smoking among Aboriginal health workers may affect their capacity to deliver smoking cessation activities (see Section 8.15.2). Specific tobacco action programs targeting Aboriginal health workers are discussed in Section 8.10.6.1. The prevalence of smoking among health workers is also discussed in Section 8.3.8.

8.6.6.3 Children and teenagers

See Section 8.4 Smoking among Aboriginal and Torres Strait Islander children and teenagers.

References

1. Australian Bureau of Statistics. 4715.0 - National Aboriginal and Torres Strait Islander Health Survey, 2018-19, in ABS2019: Canberra. Available from: https://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4715.0Main%20Features152018-19?opendocument&tabname=Summary&prodno=4715.0&issue=2018-19&num=&view=.

2. 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

3. Hyland A, Borland R, Li Q, Yong HH, McNeill A, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006; 15(suppl. 3):iii83–94. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii83

4. 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

5. 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

6. Thomas DP, Briggs VL, Couzos S, Panaretto KS, van der Sterren AE, et al. Use of nicotine replacement therapy and stop-smoking medicines in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. Medical Journal of Australia, 2015; 202(S10):S78-S84. Available from: https://onlinelibrary.wiley.com/doi/abs/10.5694/mja15.00205

7. Kennedy M, Barrett E, Heris C, Mersha A, Chamberlain C, et al. Smoking and quitting characteristics of Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study. Med J Aust, 2022; 217 Suppl 2:S6-S18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35842912

8. 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.

9. Thomas DP, Lyons L, and Borland R. Predictors and reasons for starting and sustaining quit attempts in a national cohort of Aboriginal and Torres Strait Islander smokers. Drug Alcohol Rev, 2019; 38(3):244-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30860306

10. 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.

11. 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

12. 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

13. 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

14. 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.

15. Thomas DP, Davey M, van der Sterren AE, Panaretto KS, and Lyons L. Do stress, life satisfaction, depression and alcohol use predict quitting among Aboriginal and Torres Strait Islander smokers? Australian and New Zealand Journal of Public Health, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32459387

16. Thomas DP and Panaretto KS. Predictors and reasons for quitting smoking in remote Aboriginal and Torres Strait Islander communities. Health Promotion Journal of Australia, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33749952

17. Rahman T, Baker AL, Gould GS, Palazzi K, Lambkin D, et al. Factors Associated with Smoke-Free Pregnancy among Aboriginal and Torres Strait Women and Their Experience of Quitting Smoking in Pregnancy: A Mixed Method Cross-Sectional Study. International Journal of Environmental Research and Public Health, 2021; 18(21). Available from: https://www.ncbi.nlm.nih.gov/pubmed/34769756

18. Australian Institute of Health Welfare. Aboriginal and Torres Strait Islander mothers and babies. Canberra: AIHW, 2023. Available from: https://www.aihw.gov.au/reports/mothers-babies/indigenous-mothers-babies.

19. 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.

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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/.

27. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. East Melbourne, Vic: RACGP, 2019. Last update: Viewed 1st October 2021. Available from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation/pharmacotherapy-for-smoking-cessation.

28. 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

29. Kennedy M and Maddox R. Ngaaminya (find, be able to see): summary of key findings from the Which Way? project. Medical Journal of Australia, 2022; 217(S2):S27-S9. Available from: https://onlinelibrary.wiley.com/doi/abs/10.5694/mja2.51622

30. 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

31. 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

32. 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

33. Harris BM, Harris ML, Rae K, and Chojenta C. Barriers and facilitators to smoking cessation within pregnant Aboriginal and/or Torres Strait Islander women: An integrative review. Midwifery, 2019; 73:49-61. Available from: https://www.sciencedirect.com/science/article/pii/S0266613819300531

34. Rahman T, Weatherall A, Kennedy M, Baker AL, and Gould GS. My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy. Women Birth, 2022. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35918279

35. Mersha AG, Maddox R, Maidment S, Booth K, Briscoe K, et al. "It Needs a Full-Time Dedicated Person to Do This Job in Our Local Communities with Our Aboriginal Health Services"-Aboriginal and Torres Strait Islander Health Workers and Practitioners Perspectives on Supporting Smoking Cessation during Pregnancy. International Journal of Environmental Research and Public Health, 2022; 20(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/36612349

36. 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: http://www.ncbi.nlm.nih.gov/pubmed/9489201

37. 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.

38. 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

39. 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

40. 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

41. 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.

42. 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