9A.1.1 Trends in the prevalence of smoking
More than one quarter (29%) of Australians live in regional and remote areas, and these people often have poorer health and welfare outcomes compared with people living in major cities.1 One contributor to these poorer outcomes is the significantly higher prevalence of smoking: in 2019, 13% of Australians aged 14+ living in major cities reported current smoking, compared with 19% of those in outer regional areas, and 23% of those in remote/very remote areas. Prevalence has declined among all groups over time; however, data from Australia’s National Drug Strategy Household Survey suggests that prevalence for people living in outer regional and remote areas is still higher than that of major cities a decade ago—see Figure 9A.1.1.
Proportion of current (daily, weekly, or less than weekly) smokers by geography, Australians aged 14+, 2010–2019
Source: Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data
Data from the ABS also shows much higher daily smoking prevalence among Australians living in inner regional areas (12.2%) and outer regional and remote areas (17.9%) in 2020-21, compared with those living in major cities (9.3%).2 Research in the US3 and Canada4 has similarly shown large disparities in tobacco use between urban and rural populations.
9A.1.2 Contribution of smoking to health outcomes and social inequality
People living in regional and remote areas of Australia report higher rates of some smoking-related diseases; in 2017–18, people living outside major cities had higher rates of arthritis, asthma and diabetes.1 In 2018, after adjusting for age, the total burden of disease and injury in Australia increased with increasing remoteness. The rate of disease burden in remote and very remote areas was 1.4 times as high as that for major cities.5 Life expectancy also decreases with increasing remoteness. In 2018, males living in very remote areas had a mortality rate 1.5 times as high as those living in major cities, and females living in very remote areas had a mortality rate 1.7 times as high (age-standardised). 1 One study found that smoking was the most important predictor of poor self-rated health among regional Australians.6
Compared with people in regional areas and major cities, those living in remote and very remote areas often have poorer access to, and use of, health care services. They are also less likely to participate in breast and bowel cancer screening, have higher rates of potentially avoidable hospitalisations, and lower access to selected hospital procedures.7 Because health professionals are in such short supply in rural and remote areas, it is often difficult to prioritise preventive health activities. The 2012 National Strategic Framework for Rural and Remote Health called for:
- improved access to healthcare
- effective and appropriate and sustainable healthcare delivery
- an appropriate, skilled and well-supported health workforce
- collaborative health service planning and policy development and strong leadership, governance, transparency and accountability.8
However this strategy has not been updated or evaluated, and calls have been made to use existing evidence to inform a cohesive, whole-of-system approach and updated national strategy to improve rural and remote health outcomes.9
9A.1.3 Interventions for reducing smoking
People who live in rural and remote areas face unique challenges regarding smoking cessation, including physical and social isolation, traditionally greater exposure to tobacco marketing, high rates of smoking among friends and family, and lower education and socioeconomic levels.10, 11 Low levels of self-efficacy and perceived enjoyment and benefits of continuing to smoke can also hinder quit attempts among rural smokers.12 Living some distance from major population centres, people living in rural and remote Australia often lack access to specialist medical and other health services.13 Further, to date there has been relatively little research or evaluation of smoking cessation interventions delivered to people living in rural and remote areas, leading to a lack of strong evidence regarding the most effective way to reduce smoking among this group.10
The draft 2022–30 National Tobacco Strategy includes as one of its priority areas strengthening efforts to prevent and reduce tobacco use among populations with a high prevalence of tobacco use, including those living in regional and remote areas. Actions to achieve this include targeted policies and programs; embedding cessation interventions into all forms of social, community and healthcare settings; and increasing awareness of evidence-based cessation support,14 the most effective being a combination of behavioural counselling and cessation medications.15 In Australia, subsidies of cessation medications have clearly been associated with increased access and use, particularly among concession card holders (see Section 9.9). An analysis of Pharmaceutical Benefits Scheme (PBS) data also found that Australian smokers residing in regional and remote communities were just as likely to receive a cessation medication as participants residing in major cities.16 Since 2011, all Australians have been able to access subsidised over-the-counter nicotine replacement therapy patches, and lozenges and gum were also added to the PBS in 2018. Bupropion and varenicline are only available on prescription, but have been available on Australia’s PBS since 2001 and 2008 respectively (see Section 7.16).
For smokers living in regional and remote areas, telephone- and internet-based cessation support may help to overcome limited access to behavioural support. Researchers in the US found that a text-based cessation intervention was feasible, acceptable and easily disseminated to rural older people who smoke.17 Australian researchers examined the connectivity of real-time video smoking cessation sessions and telephone calls in rural and remote locations, and found that such interventions were feasible, with minimal connectivity difficulties.18 An evaluation of video counselling among daily smokers in regional and remote NSW found that most participants found the intervention acceptable and helpful, though some aspects were rated less favourably than telephone counselling, suggesting that there may be room for enhancements.19 See Section 7.14 for a detailed discussion of telephone- and Internet-based cessation interventions.
The role of health professionals in rural and remote areas in promoting cessation at every opportunity is important despite lack of services in many regions.3,6,20,21 Interviews with Australian healthcare staff in rural-remote communities identified a number of challenges in implementing smoking cessation programs, including a lack of resources and client access to services; limited collaboration between health services; the difficulty of accessing staff training; high levels of community distress and disadvantage; the normalisation of smoking; and low morale among health staff. In order to overcome these challenges, staff suggested appointing tobacco-dedicated staff; improving health service collaboration, access and flexibility; providing subsidised pharmacotherapies; and boosting staff morale.22 Electronic health records can also be used in rural settings to document smoking and remind healthcare staff of cessation guidelines.23
“10,000 Lives” is a regional smoking cessation initiative launched by Central Queensland Hospital and Health Service in 2017, which focused on maximising the use of existing cessation services available in the region. 24 A survey of possible stakeholders in the program (e.g., workers in hospitals, health services and community organisations) found that while nearly half of respondents reported providing smoking cessation support (47.3%), less than a quarter of respondents identified as being involved in the “10,000 lives” program. Those who self-identified as being involved in the initiative were more likely to provide smoking cessation support, highlighting the importance of ongoing engagement with stakeholders to ensure program success.25
Relevant news and research
For recent news items and research on this topic, click here. ( Last updated November 2022
1. Australian Institute for Health and Welfare. Australia's health 2020. 2020. Available from: https://www.aihw.gov.au/reports-data/australias-health
2. Australian Bureau of Statistics. Pandemic insights into Australian smokers, 2020-21. 2021. Available from: https://www.abs.gov.au/articles/pandemic-insights-australian-smokers-2020-21
3. Buettner-Schmidt K, Miller DR, and Maack B. Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes. West J Nurs Res, 2019:193945919828061. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30774036
4. Li FX, Robson PJ, Ashbury FD, Hatcher J, and Bryant HE. Smoking frequency, prevalence and trends, and their socio-demographic associations in Alberta, Canada. Canadian Journal of Public Health, 2009; 100(6):453-8. Available from: https://pubmed.ncbi.nlm.nih.gov/20209740
5. Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2018. Canberra: AIHW, Australian Government 2021. Available from: https://www.aihw.gov.au/reports/burden-of-disease/abds-impact-and-causes-of-illness-and-death-in-aus/summary
6. Haines HM, Cynthia O, Pierce D, and Bourke L. Notwithstanding high prevalence of overweight and obesity, smoking remains the most important factor in poor self-rated health and hospital use in an Australian regional community. AIMS Public Health, 2017; 4(4):402-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29546226
7. Australian Institute for Health and Welfare. Rural and remote health. 2020. Available from: https://www.aihw.gov.au/reports/australias-health/rural-and-remote-health
8. Standing Council on Health, National strategic framework for rural and remote health PANDORA electronic collection., ed. Australia R and Regional Health A. [Canberra]: [Rural and Regional Health Australia]; 2012. Available from: http://nla.gov.au/nla.arc-149260.
9. Wakerman J and Humphreys JS. “Better health in the bush”: why we urgently need a national rural and remote health strategy. Medical Journal of Australia, 2019; 210(5):202-3.e1. Available from: https://onlinelibrary.wiley.com/doi/abs/10.5694/mja2.50041
10. Lum A, Skelton E, McCarter KL, Handley T, Judd L, et al. Smoking cessation interventions for people living in rural and remote areas: a systematic review protocol. BMJ Open, 2020; 10(11):e041011. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33208333
11. Ozga JE, Romm KF, Turiano NA, Douglas A, Dino G, et al. Cumulative disadvantage as a framework for understanding rural tobacco use disparities. Experimental and Clinical Psychopharmacology, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34014742
12. Hutcheson TD, Greiner KA, Ellerbeck EF, Jeffries SK, Mussulman LM, et al. Understanding smoking cessation in rural communities. Journal of Rural Health, 2008; 24(2):116-24. Available from: https://pubmed.ncbi.nlm.nih.gov/18397444/
13. Ministerial Council on Drug Strategy. Australian National Tobacco Strategy 2004-2009. Canberra: Department of Health and Ageing, 2005. Available from: https://untobaccocontrol.org/impldb/wp-content/uploads/reports/Australia_annex7_national_tobacco_strategy2004_2009.pdf
14. Consultation Draft National Tobacco Strategy 2022-2030. Canberra: Commonwealth of Australia, 2022. Available from: https://consultations.health.gov.au/atodb/national-tobacco-strategy-2022-2030/supporting_documents/Draft%20NTS%2020222030%20for%20consultaion%20hub.pdf.
15. US Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, 2020. Available from: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
16. Skinner A, Havard A, Tran DT, and Jorm LR. Access to subsidized smoking cessation medications by Australian smokers aged 45 years and older: A population-based cohort study. Nicotine & Tobacco Research, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27613898
17. Noonan D, Silva S, Njuru J, Bishop T, Fish LJ, et al. Feasibility of a text-based smoking cessation intervention in rural older adults. Health Education Research, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29309599
18. Byaruhanga J, Paul CL, Wiggers J, Byrnes E, Mitchell A, et al. Connectivity of Real-Time Video Counselling Versus Telephone Counselling for Smoking Cessation in Rural and Remote Areas: An Exploratory Study. International Journal of Environmental Research and Public Health, 2020; 17(8). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32331356
19. Byaruhanga J, Wiggers J, Paul CL, Byrnes E, Mitchell A, et al. Acceptability of real-time video counselling compared to other behavioural interventions for smoking cessation in rural and remote areas. Drug and Alcohol Dependence, 2020; 217:108296. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32980788
20. Chapman A, Bunker S, Dunbar J, Philpot B, McNamara K, et al. Rural smokers–A prevention opportunity. Australian Family Physician, 2009; 38(5):352–6. Available from: https://www.racgp.org.au/afp/2009/may/rural-smokers
21. Ramsey AT, Baker TB, Pham G, Stoneking F, Smock N, et al. Low burden strategies are needed to reduce smoking in rural healthcare settings: A lesson from cancer clinics. International Journal of Environmental Research and Public Health, 2020; 17(5). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32155775
22. Tall JA, Brew BK, Saurman E, and Jones TC. Implementing an anti-smoking program in rural-remote communities: challenges and strategies. Rural Remote Health, 2015; 15(4):3516. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26530272
23. Talbot JA, Ziller EC, and Milkowski CM. Use of electronic health records to manage tobacco screening and treatment in rural primary care. Journal of Rural Health, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34468036
24. Khan A, Green K, Khandaker G, Lawler S, and Gartner C. How can a coordinated regional smoking cessation initiative be developed and implemented? A programme logic model to evaluate the '10,000 Lives' health promotion initiative in Central Queensland, Australia. BMJ Open, 2021; 11(3):e044649. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33771827
25. Khan A, Green K, Smoll N, Khandaker G, Gartner C, et al. Roles, experiences, and perspectives of the stakeholders of "10,000 Lives" smoking cessation initiative in Central Queensland: findings from an online survey during COVID-19 situation. Health Promotion Journal of Australia, 2022. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35322498