9A.2 Culturally and linguistically diverse groups

9A.2.1 Trends in the prevalence of smoking

According to the 2021 Census, over one-quarter (27.6%) of Australian residents were born overseas, and more than one-fifth (22.3%) of the population spoke a language other than English at home.¹ Australia is one of the most culturally and linguistically diverse (CALD) populations in the world. Among the top 10 migrants’ countries that came to Australia in 2020, seven were non-English speaking, and six were from South and Southeast Asia.²

Generally speaking, people born outside of Australia are less likely to smoke than those born in Australia. Similarly, the prevalence of smoking is higher in English-speaking households compared with those that mainly speak a language other than English. However, there is considerable variation in prevalence of smoking among individuals born in different countries who have migrated to Australia.³ Smoking prevalence in 2022–23 among those aged 18 years and older born in each of several major regions of the world are set out in Table 9A.2.1.

It is important to note that in some of these regions, the prevalence of smoking is substantially higher among men than women. Table 9A.2.2 shows smoking status by gender for each of these regions and for main language spoken at home in 2022–23. While current smoking is similar among men and women born in Australia, prevalence is double or more among men in some of these regions. Smoking is very uncommon among women born in Asia and Sub-Saharan Africa. Current smoking prevalence was similar among men born in and outside of Australia (all regions combined, controlling for age) and among men who speak English and those who speak a language other than English at home. Among women, smoking prevalence was significantly lower among those born outside Australia and among those who speak a language other than English at home.³

As well as concealing sex differences, the regional summaries provided in Table 9A.2.1 are likely to disguise higher smoking rates within some smaller population sub-groups.⁴ For example, small studies have found that as many as half of men with Chinese or Vietnamese backgrounds in Sydney reported smoking at the time the surveys were conducted.^5,6 A study of Arabic-speaking patients seen in the general practice setting in New South Wales found that almost one-third currently smoked. People who smoked were also more likely to report poorer overall health and high nicotine dependence. Nicotine dependence was highest in Arabic-speaking males.⁷ A study of Australians over 45 found that compared with Australian-born men, a higher proportion of men born in Europe, North Africa, and the Middle East currently smoked.⁸ Earlier research found that Vietnamese men, Pasifika men and women, and Italian men reported higher smoking prevalence than the overall Australian population.⁹ Compared with Australian-born women, a lower proportion of women from East and South-East Asia aged over 45 currently smoked and a higher proportion of women from New Zealand and the UK/Ireland currently smoked.⁸

Although adult prevalence of smoking is higher in some groups with a non-English speaking background, studies from New South Wales have consistently shown that children within these families have a lower prevalence of smoking than their counterparts from English-speaking homes.^5,10,11

Table 9A.2.3 shows the prevalence of regular (daily or weekly) smoking among Australians aged 18+ by country of birth and main language spoken at home between 2001 and 2022–23. Regular smoking significantly declined among those born in and outside of Australia, and among those who speak English and those who speak a language other than English at home, between 2001 and 2022–23 (controlling for age and sex). Between the two most recent surveys, smoking prevalence declined among those born in and outside of Australia and among those who speak English at home, but did not change among those who speak a language other than English at home.

9A.2.2 Contribution of smoking to health outcomes and social inequality

Immigrant populations generally enjoy better reported health and lower rates of disability and hospitalisation than those reported by people born in Australia.¹² Lower rates of smoking, healthier diets, fewer sedentary hours, and the greater likelihood of migration among those with greater means and health can help explain these patterns.¹³ However, as noted above, these generalisations can mask higher rates of morbidity and mortality from smoking-related diseases among specific culturally and linguistically diverse populations that have higher smoking rates.¹⁴ For example, Australian research has found that while immigrants from English speaking countries had better physical health than native-born people, those from non-English speaking countries had typically poorer physical and mental health outcomes.¹⁵ Participation in preventative health care, such as cancer screening, is also lower among some culturally and linguistically diverse groups,¹⁶ and some groups can face substantial barriers to accessing health services.² Further, the greater health experienced by migrants can diminish over time, with one longitudinal study showing convergence between immigrants and those born in Australia in terms of reporting a chronic condition and number of chronic conditions after 20 years of residence in Australia.¹⁷

9A.2.3 Explanations for higher smoking prevalence

People from cultural backgrounds where smoking is highly prevalent may continue to smoke at much higher rates than the general population in their new country. Cultural and social norms, experiences of discrimination, and resettlement stress related to schooling, employment, and absence of social networks, can help to maintain smoking among ethnically diverse groups and immigrant populations.^18-20 Sociodemographic factors that can predict smoking among the general population, such as low education and income, may be less important than cultural factors among immigrant populations.²¹ Use of tobacco products can promote feelings of belonging and cultural identity,²² and smoking may be perceived as an enjoyable and important part of life.²³ Offering and sharing cigarettes as a sign of respect and to facilitate socialisation is a common practice within Chinese culture.^24,25 Smoking may also be tied to ideas of masculinity among men in many CALD groups in Australia.^23,26

Conversely, people from countries with very low smoking prevalence may face increased risk of taking up smoking as they adopt the norms of their new country. Smoking rates among women immigrants from non-Western countries (where smoking is typically rare) may increase as they acculturate and adopt new social norms.^27,28 A Canadian study of overseas-born children found that the likelihood of smoking increased with the years spent living in Canada.²⁹ A similar finding was made in the US, where the odds of ever use of tobacco among Hmong American youth increased the longer they had spent living in the US.³⁰ In Australia, the risk of smoking appears to increase among women born in Asia the younger they had migrated.⁸ Another Australian study found that smoking prevalence among immigrants from non-English speaking countries, who had lower odds of smoking, converged towards the native-born after 20 years of living in Australia. The effect was stronger again among those who had arrived in Australia as a child or teenager.³¹

Providing education and support to Australians from diverse cultural backgrounds is an essential component of public health programs in Australia:³² some groups may be more difficult to reach with tobacco control campaigns and other strategies.⁴ For example, there has traditionally been a lack of culturally relevant anti-smoking campaigns²³ due to factors such as cost and lack of resources, limited research to inform campaign content, and language barriers.³³ People from cultural backgrounds where smoking is highly prevalent may face cultural resistance and unique barriers to quitting,^34,35 such as a lack of awareness of or access to healthcare and cessation support, and scepticism about the effectiveness of interventions.³⁶ The role of willpower in quitting is often emphasised,^23,26,37 with relatively low use of pharmacotherapies for quitting.³⁸ Patterns of tobacco use and types of products used can differ between groups; for example, waterpipe use is highly prevalence among Arabic- and Hindi-speaking communities.^22,23 Each of these factors necessitates tailored and targeted cessation interventions.

9A.2.4 Interventions for reducing smoking

Interventions for culturally and linguistically diverse people who smoke should acknowledge heterogeneity in racial—ethnic identities and consider their unique patterns of risk and protective factors, as well as other potentially relevant dimensions such as values, beliefs and practices.^14,39,40 Qualitative research in Sydney found that among Arabic speakers, male smoking was normalised in home, social and religious settings. While there was concern about children's exposure to secondhand smoke, there was less concern for adults, particularly wives. Smoking created conflict within families, and attempts to quit were often unassisted. There was a lack of enthusiasm for telephone support services, however participants suggested that free NRT and programs in religious settings might be useful strategies.³⁵ Another Australian study found that despite high rates of smoking among Arabic-speaking communities, its social acceptability is declining due to health and financial impacts, and preventing use among young people is prioritised.²⁶ Interviews with CALD groups in NSW similarly found that the high cost of cigarettes, health effects, and social stigma were cited as reasons for disliking smoking, though few participants felt an urgency to quit.²³

A number of systematic reviews and a meta-analysis have reported promising results for the effectiveness of culturally tailored cessation interventions including adapting or building on existing cessation interventions developed for general populations.^41,42 Tailored cessation interventions can provide culturally sensitive support and help people who smoke to overcome unique barriers to quitting.⁴³ Studies that have examined the effectiveness of interventions that are adapted and tailored based on language and culture have generally shown feasibility and/or effectiveness.^44-53 For example, tailored text messaging interventions can increase motivation to quit⁵⁴ and allow for broad reach at low cost.⁵⁵ Building social support, self-efficacy and positive affect may also help to support quit attempts.^56,57 Cultural traditions may also provide unique opportunities to promote quitting; for example, fasting during Ramadan among Muslims who smoke, many of whom cut down or temporarily abstain during this time.^58-61 Tobacco control strategies should aim to not only increase motivation to quit among CALD people who smoke, but also to increase the success of quit attempts.⁶²

Interventions that target products disproportionately used by certain CALD communities, such as waterpipes/shishas, are also needed to reduce tobacco use.²² Waterpipe-specific cessation programs can address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit.⁶³ A randomised controlled trial concluded that brief behavioural cessation treatment for waterpipe users appears to be feasible and effective.⁶⁴ A 2015 review of cessation interventions concluded that people who received either behavioural treatment or behavioural treatment plus bupropion were more likely to quit waterpipe smoking at six months follow-up than those who received usual care.⁶⁵ A subsequent systematic review concluded that there is a lack of evidence of effectiveness for most interventions for waterpipe smoking. Limited evidence supports bupropion/behavioural support and group behavioural support.⁶⁶ Another review also found that brief interventions and web-based tailored information may increase waterpipe users’ intentions to quit.⁶⁷ Varenicline does not appear to be effective for waterpipe users.^68,69

Community campaigns appear to be effective in promoting quitting among waterpipe users,⁶⁷ and recognition of the role and the influence of culture and family in smoking and quitting among specific language groups is important when developing anti-smoking campaign messages. Further, research with CALD groups in NSW suggests that messages that focus on the short-term harms of smoking on a person’s finances, children, family and friends may be the most effective.²³ Participants in this research also reported that they avoid or cover pack health warnings,²³ which is known to be associated with quitting behaviours.⁷⁰ Healthcare providers can also play an important role in promoting cessation among CALD groups⁷¹ and reducing secondhand smoke exposure among children.⁷² Increasing the use of cessation medications and behavioural counselling may help increase the success of quit attempts,^73-75 particularly as some cultural groups lack awareness and use of evidence-based cessation support.³⁸ Researchers examining the effectiveness of cessation aids and strategies may also wish to be cognisant of the traditional underrepresentation of diverse groups, and ensure that recruitment methods are inclusive and effective for CALD people who smoke.^46,76

Some culturally specific programs have been initiated by various Australian organisations.^77,78 The Quitline service provides access to many printed resources in a range of community languages, and callers can request an interpreter.⁷⁹ However, interviews in NSW found that many CALD people who smoke were unaware of this service. Further, when shown a Quitline brochure in their language, most participants thought that it was too long and complex and that the content was unclear or irrelevant, though those over the age of 35 responded more favourably.²³ There is limited research on the effectiveness of telephone counselling for CALD communities; one Australian study in 2011 found that a telephone support service for Arabic people who smoke was acceptable, but did not increase abstinence.⁸⁰ Research in the US showed that receiving tobacco treatment from Quitline in a person’s preferred language appears to increase effectiveness.⁸¹ Australian researchers have highlighted that messages targeting CALD groups should highlight the benefits of cessation aids, including Quitline services.²³ In 2024, a public education campaign (‘The Hanky’) was launched in Victoria that was developed by Quit in collaboration with a multicultural specialist agency campaign. The campaign aims to raise awareness of the health risks of smoking and was specifically designed for Arabic-speaking, Mandarin-speaking and Vietnamese-speaking communities, who have much higher smoking rates than the average Victorian population.^82,83

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References

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