9A.2.1 Trends in the prevalence of smoking
According to the 2016 Census, over one quarter (28.5%) of Australian residents were born overseas,1 and more than one-fifth (21%) of Australians spoke a language other than English at home.2 Australia’s 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.3
Generally speaking, people born outside of Australia are less likely to be smokers 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.4 Smoking rates in 2019 among those 14 years 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. As well as concealing sex differences, the regional summaries provided in Table 1.8.1 are likely to disguise higher smoking rates within some smaller population sub-groups.5 For example, small studies have found that as many as half of men with Chinese or Vietnamese backgrounds in Sydney were smokers at the time the surveys were conducted.6, 7 A study of Arabic-speaking patients seen in the general practice setting in New South Wales found that almost one-third were smokers. Smokers were also more likely to report poorer overall health and high nicotine dependence. Nicotine dependence was highest in Arabic-speaking males.8 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 were current smokers.9 Earlier research found that Vietnamese men, Pasifika men and women, and Italian men reported higher smoking prevalence than the overall Australian population.10 Compared with Australian-born women, a lower proportion of women from East and Southeast Asia aged over 45 were current smokers and a higher proportion of women from New Zealand and the UK/Ireland were current smokers.9
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.6, 11, 12
Table 9A.2.2 sets out data on regular (daily or weekly) smoking for Australians 18+ from each of the National Drug Strategy Household Surveys between 2001 and 2019. Analysis of this data indicates that in 2019, ‘New Zealand and Oceania’ (16%; comprising New Zealand, Melanesia, Micronesia and Polynesia, but excluding Hawaii13) followed by ‘North Africa and the Middle East’ (13%) were the regions with highest prevalence of regular smoking. In each of the survey years from 2004 to 2019, people who were born outside Australia were significantly less likely to be regular smokers than those born in Australia (controlling for age and sex). In 2001, there was no significant difference between groups. In all years, the prevalence of smoking was significantly higher in households in which the main language spoken at home was English, compared with those who mainly spoke a language other than English at home (again controlling for age and sex).
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.21 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.22 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.23 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.24 Participation in preventative health care, such as cancer screening, is also lower among some culturally and linguistically diverse groups,25 and some groups can face substantial barriers to accessing health services.3 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.26
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.27, 28 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.29 Use of tobacco products can promote feelings of belonging and cultural identity,30 and smoking may be perceived as an enjoyable and important part of life.31 Interviews with Chinese speakers in Canada highlighted the common practice of offering and sharing cigarettes as a sign of respect and to facilitate socialisation.32 Smoking may also be tied to ideas of masculinity among men in many CALD groups in Australia.31, 33
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.34 A Canadian study of overseas-born children found that the likelihood of smoking increased with the years spent living in Canada.35 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.36 In Australia, the risk of smoking appears to increase among women born in Asia the younger they had migrated.9 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.37
Providing education and support to Australians from diverse cultural backgrounds is an essential component of public health programs in Australia:38 some groups of smokers may be more difficult to reach with tobacco control campaigns and other strategies.5 For example, there has traditionally been a lack of culturally relevant anti-smoking campaigns.31 People from cultural backgrounds where smoking is highly prevalent may face cultural resistance and unique barriers to quitting,39, 40 such as a lack of awareness of or access to healthcare and cessation support, and scepticism about the effectiveness of interventions.41 The role of willpower in quitting is often emphasised,31, 33, 42 with relatively low use of pharmacotherapies for quitting.43 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.30, 31 Each of these factors necessitates tailored and targeted cessation interventions.
9A.2.4 Interventions for reducing smoking
Interventions for culturally and linguistically diverse smokers should consider their unique patterns of risk and protective factors, as well as other potentially relevant dimensions such as values, beliefs and practices.23, 44 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.40 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.33 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.31
A systematic review of adapted cessation interventions for ‘ethnic minority groups’ found that while such interventions are more acceptable, this does not translate into improvements in smoking cessation outcomes.23 Another systematic review reported more promising results for the effectiveness of specific cultural adaptations for cessation, and highlighted that interventions may be more effective if adaptations are implemented as a package, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention.45 A growing number of more recent studies are examining the effectiveness of interventions that are adapted and tailored based on language and culture, with findings generally showing feasibility and/or effectiveness.46-52 For example, tailored text messaging interventions can allow for broad reach at low cost.53 Building social support, self-efficacy and positive affect may also help to support quit attempts.54, 55 Cultural traditions may also provide unique opportunities to promote quitting; for example, fasting during Ramadan among Muslim smokers, many of whom cut down or temporarily abstain during this time.56-58
Interventions that target products disproportionately used by certain CALD communities, such as waterpipes/shishas, are also needed to reduce tobacco use.30 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.59 A randomised controlled trial concluded that brief behavioural cessation treatment for waterpipe users appears to be feasible and effective.60 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.61 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.62 Another review also found that brief interventions and web-based tailored information may increase waterpipe users’ intentions to quit.63 Varenicline does not appear to be effective for daily waterpipe users.64
Community campaigns appear to be effective in promoting quitting among waterpipe users,63 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.31 Participants in this research also reported that they avoid or cover pack health warnings,31 which is known to be associated with quitting behaviours.65 Healthcare providers can also play an important role in promoting cessation among CALD groups.66 Increasing the use of cessation medications and behavioural counselling may help increase the success of quit attempts,67-69 particularly as some cultural groups lack awareness and use of evidence-based cessation support.43 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 smokers.48, 70
Some culturally specific programs have been initiated by various Australian organisations, mostly on a short-term basis.71, 72 The Quitline service provides access to many printed resources in a range of community languages, and callers can request an interpreter.73 However, interviews in NSW found that many CALD smokers 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.31 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 smokers was acceptable, but did not increase abstinence.74 Australian researchers have highlighted that messages targeting CALD groups should highlight the benefits of cessation aids, including Quitline services.31
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