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Last updated: March 2023
Suggested citation: Greenhalgh, EM, Jenkins, S, van der Sterren, A, Knoche, D, & Winstanley, MH 8.7 Morbidity and mortality caused by smoking 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; 2023. Available from http://www.tobaccoinaustralia.org.au/8-7-morbidity-and-mortality-caused-by-smoking-amon
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This section discusses the major tobacco related disease groups leading to illness and death among Aboriginal and Torres Strait Islander peoples. The health consequences of smoking are discussed in detail in Chapter 3 . National figures on morbidity and mortality due to smoking are provided in Chapter 3, Section 3.30.
8.7.1 Causes of mortality and morbidity among Aboriginal and Torres Strait Islander peoples
The health of Aboriginal and Torres Strait Islander peoples is affected by complex and inter-related factors that reflect the ongoing experience and mechanisms of colonisation, including experiences of marginalisation, socioeconomic disadvantage, family dislocation, racism, disconnection from land, loss of traditional diet and lifestyle, and the subsequent adoption and adaption of Western habits and practices. 1,2 The 2023 Aboriginal and Torres Strait Islander Health Performance Framework report highlighted that the health of Aboriginal and Torres Strait Islander peoples has improved on a number of measures over the past decade, including decreases in death rates for cardiovascular disease and kidney disease. The prevalence of smoking—a key health risk factor—has also continued to decline. However, the proportion of low birthweight babies, the prevalence of perinatal deaths, child deathsand the prevalence of diabetes have not improved significantly. In addition, the prevalence of obesity and rates of death from cancer and suicide have increased.3 The Australian Burden of Disease study reports that in 2018, Aboriginal and Torres Strait Islander peoples lost a total of 240,000 years of healthy life (‘disability-adjusted life years’ or DALYs) due to living with illness and injury (53% of total burden) and dying prematurely (47% of total burden). The largest disease group contributors to total burden were mental and substance use disorders (23% of total burden), followed by injuries (12%), cardiovascular diseases (10%), cancer (9.9%) and musculoskeletal conditions (8.0%). Overall, the health of Aboriginal and Torres Strait Islander peoples had improved over the 15-year period from 2003 to 2018. After adjusting for population growth and ageing, there was a 15% decline in total burden, driven by a substantial decline in fatal rather than non-fatal burden.4
8.7.2 Morbidity and mortality attributable to tobacco use
The Australian Burden of Disease study provides details on the burden attributable to the leading risk factors for Aboriginal and Torres Strait Islander peoples. In 2018, tobacco use accounted for 11.9% of the burden of disease, more than any other risk factor. After taking into account population growth and ageing, the age-standardised rate of burden attributable to tobacco use decreased 11% between 2003 and 2018 (from 65.8 per 100,000 to 58.8 attributable DALYs). More than 800 deaths (23% of all deaths) were attributed to tobacco use in 2018. Tobacco use contributed to the burden for nine disease groups, including 47% of respiratory diseases, 37% of cancers, 34% of cardiovascular diseases, 13% of infectious diseases and 10% of endocrine disorders. The overall burden attributable to tobacco use increased with age, and became the leading risk factor contributing to disease burden among both men and women after age 45.4
A number of studies have attempted to quantify deaths due to smoking among Aboriginal and Torres Strait Islander peoples.5-9Research published in 2021 estimated that that smoking causes 37% of all deaths, and 50% of deaths at age 45 years and over, in Aboriginal and Torres Strait Islander peoples. This equates to more than 10,000 preventable premature deaths between 2009 and 2018. Compared with current smokers, those who had never smoked were about twice as likely to live to age 75, and had on average more than ten extra years of life expectancy. In line with existing evidence (see Section 18.3), smoking 1–14 cigarettes per day—so called ‘light smoking’—carried a three-fold higher mortality risk than never smoking, while quitting prior to age 45 reduced a person’s mortality risk to that of a never smoker (see also Section 7.1). Those who quit between the ages of 45 and 54 had a mortality risk half that of current smokers and double that of never smokers. These findings highlight the critical role that ongoing reductions in smoking prevalence (see Section 8.3) will have in substantially reducing premature deaths among Aboriginal and Torres Strait Islander peoples.8 , 9
Researchers have also considered the current stage of the smoking epidemic among Aboriginal and Torres Strait Islander peoples, and the short- and long-term implications. They suggest that the Aboriginal and Torres Strait Islander population is at an earlier stage of the tobacco epidemic than the total Australian population, at Stage 3 versus Stage 4 (see Section 1.3.3), and that the burden of smoking-attributable mortality is likely to remain high. The burden of tobacco-related cardiovascular disease will likely decline in the short term as smoking prevalence continues to decline. The burden of lung cancer may peak within the next decade—assuming that peak smoking prevalence occurred at or before 1994—which reflects the long lag time between smoking behaviour and the onset of tobacco-related cancer mortality.10
8.7.3 Diseases and conditions related to smoking
Tobacco is a causal, contributing or complicating factor in many diseases and conditions disproportionately experienced by Aboriginal and Torres Strait Islander peoples. This sub-section considers some of the specific diseases and conditions related to smoking: cardiovascular diseases, cancers, respiratory diseases, diabetes, and pregnancy-related conditions.
8.7.3.1 Cardiovascular diseases
People who smoke have an increased risk of most types of cardiovascular disease (CVD; a broad term for a range of diseases affecting the heart and blood vessels), and deaths are substantially higher among smokers (see Section 3.1). In 2018–19, 15% of Aboriginal and Torres Strait Islander peoples reported having cardiovascular disease. More than half (56%) of those aged 55+ years reported having CVD.11
In 2020, ischaemic heart disease was the leading specific cause of deaths in NSW, Qld, WA, SA and the NT combined, and cerebrovascular diseases were the sixth leading specific cause of deaths.12 Between 2010 and 2019, there was an 18% decrease in the death rate from CVD among Aboriginal and Torres Strait Islander people. This decline coincided with a reduction in smoking rate and increase hospitalisation for cardiovascular-related procedures.3
In 2018, CVD was responsible for 10% of the total burden of disease among Aboriginal and Torres Strait Islander peoples. The leading specific cause of burden was ischaemic heart disease, while stroke was the 16 th leading specific cause. Encouragingly, between 2003 and 2018, there was a decrease for cardiovascular diseases in age-standardised burden rates of 40 DALYs per 1,000 people, the largest change for any disease group.4
The high prevalence of smoking, diabetes, obesity and sedentary lifestyle, high blood pressure and cholesterol, and poor nutrition in the Aboriginal and Torres Strait Islander populations contributes to the incidence of cardiovascular diseases in their communities. National13 and regional14-17studies have shown a high incidence of multiple risk factors for heart disease among Aboriginal and Torres Strait Islander peoples, especially smokers.18 A consensus statement was released in 2020 recommending that Aboriginal and Torres Strait Islander peoples begin having CVD risk assessment screening from the age of 18 years because of early disease onset.19
8.7.3.2 Cancers
In 2014–18, the age-standardised incidence rate of all cancers combined for Aboriginal and Torres Strait Islander peoples living in NSW, Vic, Qld, WA and the NT was 519 per 100,000 population, the most common being breast cancer, prostate cancer, lung cancer and bowel cancer. These types of cancers relate to both modifiable risk factors, such as smoking and alcohol consumption, as well as relatively low uptake of diagnostics testing and national population-based screening programs (such as those for breast, cervical, and bowel cancer).20 Longitudinal research has found that liver/bile duct and lung are the most common cancer sites among Aboriginal and Torres Strait Islander adults living in remote communities. Overall cancer incidence was significantly higher in Torres Strait Islander than Aboriginal people.21
In the period 2015 to 2019, cancer was the leading broad cause of death for Aboriginal and Torres Strait Islander people, accounting for 23% of all deaths.3 Between 2010 and 2019, there was a 12% increase in age-standardised prevalence of deaths due to cancer among Aboriginal and Torres Strait Islanders peoples. The five-year relative survival among Aboriginal and Torres Strait Islander peoples for all cancers combined was 49% in 2014–18; for lung cancer it was 11%. 20,22
In 2018, cancer accounted for 9.9% of the total burden of disease among Aboriginal and Torres Strait Islander peoples, and of the disease groups made the fourth highest contribution to total burden. Between 2003 and 2018, there was a decrease in both the total burden attributable to all cancers of 4.0 DALYs per 1,000 people (age-standardised) and to lung cancer of 0.8 DALYs (age-standardised).4
In 2018, an estimated 37% of the burden due to cancer among Aboriginal and Torres Strait Islander peoples was attributable to smoking.23 A study published in 2018 followed a cohort of 2,273 Aboriginal and Torres Strait Islander adults from 26 remote communities in far North Queensland over 15 years, who were initially free of cancer. Findings showed that at follow-up, smokers had a 60% higher risk for all cancers combined and a fourfold risk for lung cancers compared to non-smokers, regardless of age, sex and ethnicity.21
8.7.3.3 Respiratory diseases
Aboriginal and Torres Strait Islander peoples experience high rates of respiratory diseases including asthma, chronic obstructive pulmonary disease (COPD), and pneumonia,24 all of which are caused by smoking.25 In 2018–19, 29% of Aboriginal and Torres Strait Islander people reported having a long-term respiratory condition, including asthma (16%), chronic obstructive pulmonary disease (COPD; 3.4%), and chronic sinusitis (7.4%).11 Prevalence is substantially higher among current and ex-smokers,18 and other contributing factors to respiratory and lung disease among Aboriginal and Torres Strait Islander peoples include living in dusty regions, or exposure to smoke from wood fires.26 Over2015–19, respiratory diseases were the fourth leading cause of deaths for Aboriginal and Torres Strait Islander people, responsible for 10% of total deaths. Over half (63%) of these respiratory-related deaths were from COPD.20
In 2018, COPD was also the second leading specific cause of total disease burden among Aboriginal and Torres Strait Islander peoples, and asthma the 11th. Between 2003 and 2018, there was an overall decrease in the total burden attributable to respiratory diseases of 4.1 DALYs per 1,000 people (age-standardised), as well as to COPD of 5.4 DALYs per 1,000 people (age-standardised). For asthma, there was an increase of 3.1 DALYs over time (age-standardised).4
8.7.3.4 Diabetes
Smoking is a cause of diabetes25 —a chronic condition in which blood glucose levels become too high due to the body producing little or no insulin, or being unable to use insulin properly.27 As well as being life threatening in its own right, diabetes mellitus (also known as type 2 diabetes) can lead to a range of other serious health problems, including coronary heart disease, stroke, peripheral vascular disease, kidney disease, eye disease,28 and complications in pregnancy and childbirth.29 Smokers with diabetes are also at increased risk of illness and premature death, mainly through the development of cardiovascular disease.30 Aboriginal and Torres Strait Islander peoples,13 and particularly smokers,18 may experience a number of risk factors for developing diabetes, including being overweight, having an unbalanced diet and lack of physical activity. 13,18,31,32
In 2018–19, 13% of Aboriginal and Torres Strait Islander adults had diabetes and/or were at risk of developing diabetes (i.e., had high glucose levels).11 In 2020, diabetes was the second leading cause of death for Aboriginal and Torres Strait Islander peoples in NSW, Qld, SA, WA and the NT.12 The age-standardised death rate decreased for diabetes between2006 and 2019 decreased by 20%.20
In 2018, type 2 diabetes was the fourth leading specific cause of total disease burden among Aboriginal and Torres Strait Islander peoples. Between 2003 and 2018, there was a decrease in the total burden attributable to type 2 diabetes of 10.7 DALYs per 1,000 people (age-standardised).4
8.7.3.5 Smoking in pregnancy, and maternal and child health outcomes
About two in five Aboriginal and Torres Strait Islander women report smoking during pregnancy, with higher rates again among women in disadvantaged and very remote areas. However, this proportion has decreased over time—see Section 8.3.7. The proportion of Aboriginal and Torres Strait Islander pregnant women attending antenatal visits in the first 10 weeks of pregnancy has also notably increased.33 There have also been improvements to medical care such as access to hospital birthing facilities, improved neonatal and paediatric care, and the establishment of pre-natal screening for congenital abnormalities.34
Smoking in pregnancy is a major risk factor for preterm delivery, complications in childbirth, foetal growth restriction, stillbirth, low birthweight and infant mortality (see Section 3.7).35 Poor health outcomes in pregnancy—low birthweight, premature birth, and stillbirth or death in the first four weeks of life (perinatal deaths)—are prevalent among Aboriginal and Torres Strait Islander women.In 2020, there were 13, 605 babies born to Aboriginal and Torres Strait Islander women and 249 perinatal deaths (mortality rate of 17 deaths per 1,000 births) and 14% of babies were born pre-term. Of liveborn babies, 12% had a low birthweight and 12% were for small for gestational age. Despite decreasing smoking rates in pregnancy and increasing rates of antenatal care visits, among babies of Aboriginal and Torres Strait Islander women the rates of low birthweight and pre-term births between 2005 and 2020 and small-for-gestational-age births between 2013 and 2020 have remained largely unchanged.33 The infant mortality rate also did not change significantly over the decade from 2010 to 2019.36 The rates of poor health outcome in pregnancy are similar among Aboriginal and Torres Strait Islander babies (i.e., looking at the Indigenous status of the baby rather than the mother); in 2020 13% of babies were born pre-term, 11% were low-birth weight, 12% were small for gestational age and there 14 perinatal deaths per 1000 births.33
The most common causes of death for Aboriginal and Torres Strait Islander infants over the period 2015–19 were conditions originating in the perinatal period (57%) such as birth trauma, foetal growth disorders, complications of pregnancy, and respiratory and cardiovascular disorders specific to the perinatal period. The third leading cause of death was signs, symptoms and ill-defined conditions (14%), including SIDS.36 The risks of both these categories are elevated by smoking during pregnancy. Other than smoking, factors that affect maternal and child health outcomes include socio-economic circumstances, access to healthcare facilities, and the mother’s age during pregnancy.38 Aa high proportion of Aboriginal and Torres Strait Islander females who gave birth in 2020 were aged under 20 years (11%), however the proportion has halved since 2005 (22%).33
A number of studies have specifically looked at birth outcomes in relation to smoking during pregnancy among Aboriginal and Torres Strait Islander women. In 2020, babies born to Aboriginal and Torres Strait Islander mothers who did not smoke had higher chances of being born at a normal size for gestational age (76% compared to 71% for babies whose mothers smoked), achieving a healthy birthweight (90% compared to 82% for babies whose mothers smoked), and being born at term (89% compared to 83% for babies whose mothers smoked).33 ,Over period 2017–2019, it is estimated that smoking was attributable for 37% of low birthweight births, 22% pre-term births and 39% of small for gestational age births among Aboriginal and Torres Strait Islander babies.39 A South Australian study published in 2001 also concluded that about 20% of preterm births, 48% of babies being born small for their gestational age, and 35% of babies with low birthweight could be attributed to smoking after 20 weeks in this population group.40 A larger 2019 study conducted in Western Australia found that of babies born to Aboriginal and Torres Strait Islander women 9% of preterm births, 28% of babies small for their gestational age and 19% of perinatal deaths could be attributed maternal smoking during any stage of gestation.41 A Queensland study investigating the effect of smoking on preterm births and low birthweight found that both Indigenous and non-Indigenous smokers had poorer birth outcomes than non-smokers; there was no significant difference in birth outcomes between Indigenous and non-Indigenous smokers.42 A Western Australian study found that the risk of sudden infant death syndrome for babies born to Aboriginal and Torres Strait Islander women who smoke is nearly three times greater than for babies of non-smoking Indigenous women.43 Aboriginal and Torres Strait Islander infants whose mothers smoked during pregnancy also had a 42% increased risk of hospitalisation from a respiratory syncytial virus (RSV) infection.44 Other studies of Aboriginal and Torres Strait Islander birth outcomes have found significant associations between smoking and small for gestational age, 45,46 kidney injury,47 low birthweight, 24,48-50 and ‘poor birth outcomes’ (low birthweight and/or preterm). 46,51
While the use of smokeless tobacco is relatively rare among Australians, the use of wild tobacco plants called pituri is more common among some Aboriginal and Torres Strait Islander communities in central Australia, including among pregnant women52 (see Section 8.5.3). Recent research on tobacco use among Central Australian Aboriginal women found that more than half (57%) of the infants were exposed to maternal tobacco use (26% smokeless tobacco use, 31% cigarette use). Women who used chewing tobacco had the lowest placental weight, while smokers had the lowest placental size. Newborns of women who used smokeless tobacco were more likely to be admitted to the Special Care Nursery.53 Another study with the same group of women found that tobacco chewers had a higher rate of combined pre-existing and pregnancy-related elevated glucose concentrations.54 These studies highlight the importance of screening for and addressing smokeless tobacco use among pregnant Aboriginal and Torres Strait Islander women.
8.7.4 Exposure to secondhand smoke and its health effects
Secondhand tobacco smoke also poses a major health risk. Babies and children exposed to cigarette smoke in the home experience higher rates of sudden infant death syndrome, exacerbation of asthma, a greater risk of developing acute lower respiratory tract infections such as bronchitis and pneumonia, and increased risk of middle ear infections. Adults exposed to secondhand smoke are more likely to develop a range of diseases including coronary heart disease, lung cancer and other respiratory problems.55 (See Chapter 4).
In 2018–19, about 56% of Aboriginal and Torres Strait Islander people of all ages lived in a household in which there was at least one daily smoker. Almost one in five (18%) were living in a household in which someone smoked inside.In terms of children, 57% of Aboriginal and Torres Strait Islander children aged 0–14 were living with a daily smoker in 2018–19: a significant decrease from 65% in 2008. About 9% of Aboriginal and Torres Strait Islander children lived with someone who smoked inside the home. These proportions increased with remoteness, such that children in remote areas were significantly more likely to live with a daily smoker, and to live with a daily smoker who smoked indoors, than those in non-remote areas.20
Aboriginal and Torres Strait Islander women are more likely than non-Indigenous women to be exposed to secondhand smoke during pregnancy, and this may affect birth outcomes (see Section 4.16). A study of pregnant Aboriginal women in Western Australia reported an association between exposure to secondhand smoke and an increased risk of having low birthweight and/or preterm babies.51 Similarly, a 2015 study detected serum cotinine (which indicates exposure to cigarette smoke) in just over half of a sample of pregnant Aboriginal and Torres Strait Islander women, and this was negatively associated with birth weight and gestational age at delivery.56 In a study of maternal smoking in the Northern Territory, 31% of the households of the pregnant participants included people who smoked inside during the pregnancy. Importantly, the birth of the child was associated with many of these households becoming smokefree indoors, with 12% reporting smoking indoors at one month after the birth, and 16% at seven months.57 In a 2013 qualitative study, Aboriginal and Torres Strait Islander participants described avoiding smoking if children were present, and often limited the household areas where they smoked in an attempt to protect babies and children. Some also reported showering or changing clothes after having a cigarette.58
Smaller regional studies have also reported exposure to secondhand smoke among babies born to Aboriginal and Torres Strait Islander families. Research from Western Australia in the late 1990s found that 80% of Indigenous babies in a sample studied in Perth were regularly exposed to tobacco smoke.59 A study from Queensland found that 40% of Aboriginal and Torres Strait Islander infants were exposed to smoke in the home, compared to 20% of non-Indigenous babies.60 Research from three remote top end (north Northern Territory) communities reported that 98% of Indigenous primary or high school-aged children lived with at least one smoker, and 43% lived with five or more smokers.61 Aboriginal and Torres Strait Islander children have more than three times the incidence of ear and hearing problems of non-Indigenous children,13 for which secondhand smoke is likely to be at least partially responsible. A Western Australian study found that exposure to secondhand smoke was a significant predictor of otitis media (middle ear infection) in Aboriginal children,62 which is common and frequently severe in Indigenous children,63 and is likely one of the key determinants of the high rates of disability and learning difficulties among this population.64 A study conducted in the Royal Darwin Hospital found exposure to household smoke more than doubled the likelihood of Aboriginal and Torres Strait Islander infants who were admitted to the hospital for bronchiolitis being re-admitted in the next six months.65
The comparatively high smoking rates among Aboriginal and Torres Strait Islander adults, to which colonisation contributed, means that many Aboriginal and Torres Strait Islander children live in households where smoking is normalised. This can affect both their health and their likelihood of taking up smoking—see Section 8.4.3.
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated December 2021)
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