|Last updated: August 2016
Suggested citation: van der Sterren, A, Greenhalgh, EM, Knoche, D, & Winstanley, MH 8.13 Policies for advancing tobacco control programs among Aboriginal peoples and Torres Strait Islanders. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-8-aptsi/8-13-policy-recommendations-for-advancing-tobacco-
Over the past decade, the amount of information about the use of tobacco and its impact on the health and wellbeing of Aboriginal and Torres Strait Islander populations has increased dramatically. The preceding sections have drawn on a broad range of research reports, some of which have made specific recommendations about appropriate policy directions for effective tobacco interventions in the Indigenous population.1-10 These reports and the many community members, health professionals, researchers, and policy-makers working in the area of Indigenous tobacco control have advocated a co-ordinated policy framework and action in this area supported by adequate and sustained funding. Commonwealth, state and territory governments have responded to these calls and to the emerging evidence of the harms of smoking in Indigenous communities. In the context of a public health policy environment with an increased emphasis on preventive health and a commitment to reducing Indigenous disadvantage, Australian governments at all levels have taken a co-ordinated approach to Indigenous smoking and have committed significant funding to support it. The Tackling Indigenous Smoking program will be described further below, but first it is important to have a sense of the broader policy environment relevant to Indigenous tobacco control, including the international and national policy contexts.
Action on tobacco in Aboriginal and Torres Strait Islander communities does not happen in isolation of Australia’s obligations on the international policy stage. As a signatory to the World Health Organization Framework Convention on Tobacco Control (FCTC), the Australian government has committed to ensuring that:
“Every person…be informed of the health consequences, addictive nature and mortal threat posed by tobacco consumption and exposure to tobacco smoke and effective legislative, executive, administrative or other measures should be contemplated at the appropriate governmental level to protect all persons from exposure to tobacco smoke” (Article 4.1).11
Furthermore, the FCTC specifically expresses that Parties to the Convention are ‘Deeply concerned about the high levels of smoking and other forms of tobacco consumption by indigenous peoples’ (p2).11 The Convention commits signatories to develop and support multisectoral measures and co-ordinated responses that take into consideration ‘the need to take measures to promote the participation of indigenous individuals and communities in the development, implementation and evaluation of tobacco control programmes that are socially and culturally appropriate to their needs and perspectives’ (p6).11
Current national drug policy (including both licit and illicit substances) is embodied in the National Drug Strategy 2010–2015: A Framework for Action on Alcohol, Tobacco and Other Drugs.12 Since its inception in 1985, the National Drug Strategy has advocated a harm minimisation approach with the three pillars of demand reduction, supply reduction and harm reduction. A sub-strategy of the National Drug Strategy is the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014–19 that builds upon an earlier Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2009.13 The sub-strategy sets out four priority areas directed at reducing alcohol and drug use and their related harms, and at reducing the proportion of Aboriginal peoples and Torres Strait Islanders who smoke tobacco:14
The National Tobacco Strategy is a policy framework for the Australian Government and state and territory governments to work together and in collaboration with non-government agencies to improve health and to reduce the social costs caused by tobacco.15 The first National Tobacco Strategy (1999 to 2002–03)16 recognised that concerted action was required to reduce smoking prevalence among Aboriginal and Torres Strait Islander communities. This led to the funding and launch in 2000 of the National Aboriginal and Torres Strait Islander Tobacco Control Project, a joint initiative between the National Aboriginal Community Controlled Health Organisation and the Department of Health and Aged Care.3
The current National Tobacco Strategy (2012–18)17 has been developed by the Intergovernmental Committee on Drugs Standing Committee on tobacco as a sub-strategy under the National Drug Strategy 2010–2015. It builds on its precursors (the National Tobacco Strategy 1999 to 2002–03, and 2004–2009),16, 18 and emphasises that reducing smoking among Aboriginal and Torres Strait Islander people is central to closing the gap. The report highlights a range of priorities from the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes,19 which aim to reduce the harm and inequality caused by tobacco among Indigenous Australians. These include:17
Each state and territory has developed and implemented its own tobacco strategy or action plan,20-25 or has tobacco-related strategies embedded within alcohol, tobacco and other drug strategies/action plans (i.e. Queensland26 and the Australian Capital Territory27), although some are now outdated. All of these strategies recognise Aboriginal peoples and Torres Strait Islanders as a particular target group for tobacco action. The ACT also produced the Aboriginal and Torres Strait Islander Tobacco Control Strategy, 2010/11–2013/1428 and several states have developed advisory mechanisms for the development and implementation of tobacco strategies for Indigenous peoples.
The national Preventative Health Taskforce was established in April 2008 to develop a National Preventative Health Strategy focusing on three priority areas for action: obesity, alcohol, and tobacco. In June 2009, the Taskforce released Australia: The Healthiest Country by 2020—National Preventative Health Strategy—The Roadmap for Action.29 A key action area identified in this document is to: ‘Work in partnership with Indigenous groups to boost efforts to reduce smoking and exposure to passive smoking among Indigenous Australians’. Six actions specifically related to this were recommended (p190–2):29
• establish multi-component community-based tobacco-control projects that are locally developed and delivered
• enhance social marketing campaigns for Indigenous smokers, ensuring a ‘twin track’ approach of using existing effective mainstream campaigns complemented by Indigenous specific campaign elements
• provide training to Aboriginal and Torres Strait Islander health workers to improve skills in the provision of smoking cessation advice
• improve training in the provision of smoking cessation advice of other health professionals working in Aboriginal and Torres Strait Islander health services
• place specialist tobacco-control workers in Indigenous community health organisations to build capacity at the local health service level to develop and deliver tobacco-control activities
• provide incentives to encourage non-government organisations to employ Indigenous workers.
In addition, a number of recommendations were made specifically around improving data collection on tobacco use and behaviours among Indigenous people (p198):29
All of these recommendations have been accepted by the Commonwealth Government,30 with some of these being specifically addressed in the Tackling Indigenous Smoking Initiative described below.
In 2008, the Council of Australian Governments committed to targets for closing the gap on Indigenous disadvantage in the areas of health, education, and employment. These targets included closing the life expectancy gap within a generation, and halving the gap in mortality for Indigenous children under five within a decade. Recognising the contribution of smoking to the health gap, ‘Tackling Smoking’ became a key initiative of the Council of Australian Governments’ National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes.31 Commonwealth, state and territory governments committed a total of almost $200 million over four years (2009–13) to reduce the smoking rate and the tobacco-related burden of disease within Aboriginal and Torres Strait Islander communities—$100.6 million from the Commonwealth Government and $98.09 million from the states and territories. This was to be achieved through:31
In addition to these initiatives, the Commonwealth Government provided a further $14.5 million over the same four-year period for 18 Indigenous tobacco-specific projects under the Indigenous Tobacco Control Initiative.32 A 2013 review of the first three years of the National Partnership Agreement stated that at that point it was too early to assess whether it had achieved its intended outcomes in terms of improvements to Indigenous health. Early evidence indicated improved access to healthcare, and there had been good progress in the implementation of initiatives and activities by all governments.19
The Tackling Indigenous Smoking Initiative was part of the Indigenous Chronic Disease Package (ICDP), a broader set of strategies to address chronic diseases and risk factors more generally. In the area of smoking, the following activities were planned under the leadership of a National Co-ordinator for Tackling Indigenous Smoking:32, 33
The 2013 Prime Minister’s Closing the Gap report indicated that by the end of 2012–13, Regional Tackling Smoking and Healthy Lifestyle Teams were expected to have national coverage. Nationally more than 200 health workers and community educators were trained in smoking cessation, and Quitlines were enhanced to provide more culturally appropriate services for Aboriginal and Torres Strait Islander people, including specific Indigenous positions and cultural awareness training for staff.34 A 2014 evaluation of the ICDP indicated that it has increased the focus on health promotion and preventive health among Indigenous communities, which has resulted in community members now seeking more help to, for example, quit smoking. Clinicians reported an increased interest from patients in cessation support, along with an increase in the use of smoking cessation medicines. One in three program managers reported behavioural changes among the target community members, including smoking cessation. However, health workers reported a need for long-term, sustained programs with consistent staff, which is reportedly difficult in a remote context. Aboriginal health workers also reported considerable challenges in implementing and enforcing smokefree policies at Aboriginal Health Services.35
Following a 2014 review,36 the Tackling Indigenous Smoking and Healthy Lifestyle program was redesigned to support flexible approaches to regional tobacco control. The Tackling Indigenous smoking program has a budget of $116.8 million over 3 years from 2015-16 and includes:37
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5. Department of Health South Australia. Indigenous smoking scoping study: Prepared for the South Australian department of health. Adelaide: Department of Health, 2008. Available from: http://www.health.sa.gov.au/SHRP/Portals/0/Urbis%20report%20Oct%202008.pdf.
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7. TNS Social Research. Environmental scan of tobacco control interventions in Aboriginal populations: What works? What doesn't? Final report Perth, Western Australia: WA Department of Health, 2008. Available from: http://www.health.wa.gov.au/smokefree/docs/Report_of_Audit_Aboriginal_Smoking_Prevention_Cessation_Services.pdf.
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9. Centre for Excellence in Indigenous Tobacco Control. Learning from each other: Oceania tobacco control 09 Indigenous pre-conference workshop report. Melbourne, Australia: CEITC, The University of Melbourne, 2010. Available from: http://www.ceitc.org.au/ceitc-publications-and-resources.
10. Boffa J, Tilton E, Legge D, and Genat B. Reducing the harm from alcohol, tobacco and obesity in Indigenous communities. Produced for the National Preventative Health Taskforce, Canberra: Department of Health and Ageing, 2009. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-indig-boffa.pdf.
11. Who Framework Convention on Tobacco Control. Geneva: World Health Organization, 2005. Available from: http://whqlibdoc.who.int/publications/2003/9241591013.pdf.
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13. Ministerial Council on Drug Strategy. National drug strategy. Aboriginal and Torres Strait Islander peoples complementary action plan 2003−2009. Canberra, Australia: National Drug Strategy Unit, Department of Health and Ageing, 2003. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/indigenous-drug-strategy-lp.
14. Intergovernmental Committee on Drugs. National Aboriginal and Torres Strait Islander peoples’ drug strategy 2014–2019. A sub-strategy of the national drug strategy 2010–2015. 2015. Available from: www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/natsipds2014-19
15. Department of Health. Australian Government, National Tobacco Strategy. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/tobacco-strategy
16. Ministerial Council on Drug Strategy. National Tobacco Strategy 1999 to 2002–03. A framework for action. Canberra: Commonwealth of Australia, 1999. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/09C1490BFFCC1872CA256F190004478B/$File/strategy.pdf.
17. Intergovernmental Committee on Drugs, National Tobacco Strategy 2012-2018. Australian Government; 2012. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/national_ts_2012_2018.
18. Ministerial Council on Drug Strategy. National Tobacco Strategy, 2004–2009: The strategy. Canberra: Commonwealth of Australia, 2005. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/E955EA2B5D178432CA256FD30017A522/$File/tobccstrat2.pdf.
19. Department of Health and Ageing, Joint report on the review of the national partnership agreement on closing the gap in Indigenous health outcomes. Australian Government; 2013. Available from: https://www.health.gov.au/internet/main/publishing.nsf/Content/9A629143910D8BE8CA257E340008F401/$File/joint-review_NPA-ctg_indigenous-health-outcomes.docx.
20. NSW Health, NSW tobacco strategy 2012–2017. 2012. Available from: http://www.health.nsw.gov.au/tobacco/Publications/nsw-tobacco-strategy-2012.pdf.
21. Victorian Government Department of Human Services. Victorian tobacco control strategy 2008–2013. Melbourne: Victorian Government Department of Human Services, 2008. Available from: http://www.health.vic.gov.au/tobaccoreforms/downloads/vtcs0813.pdf.
22. Department of Health Western Australia. Western Australian tobacco action plan 2007–2011. Perth: Department of Health, 2007. Available from: http://www.watap.health.wa.gov.au/docs/WATAP_2007-2011.pdf.
23. Drug and Alcohol Services South Australia. South Australian tobacco control strategy 2011–2016. Parkside: Drug and Alcohol Services South Australia, 2011. Available from: http://www.dassa.sa.gov.au/site/page.cfm?u=117#sa.
24. Department of Health and Families NT. Northern Territory tobacco action plan 2010–2013. Casuarina: Department of Health and Families, Northern Territory, 2008. Available from: http://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/48/20.pdf&siteID=1&str_title=Northern%20Territory%20Tobacco%20Action%20Plan.pdf.
25. The Tobacco Coalition. Tasmanian tobacco action plan 2011–2015. Hobart: Population Health, Department of Health and Human Services Tasmania, 2010. Available from: http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0009/53793/Tasmanian_Tobacco_Action_Plan_2011-2015.pdf.
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29. Preventative Health Taskforce. Australia: The healthiest country by 2020—national preventative health strategy—the roadmap for action. Canberra: Commonwealth of Australia, 2009. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/CCD7323311E358BECA2575FD000859E1/$File/nphs-roadmap.pdf.
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33. Department of Health and Ageing. National action to reduce Indigenous smoking rates—fact sheet. Canberra: Department of Health and Ageing, 2010. Last update: Viewed Available from: http://www.health.gov.au/internet/ctg/publishing.nsf/Content/national-action-to-reduce-indigenous-smoking-rate.
34. Australian Government. Closing the gap: Prime minister’s report. 2013. Available from: https://www.dss.gov.au/sites/default/files/documents/02_2013/00313-ctg-report_fa1.pdf
35. KPMG, National monitoring and evaluation of the Indigenous chronic disease package: Summary report. Canberra: Australian Government Department of Health; 2014. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/FD5466A9AF925775CA257D8E00000AD0/$File/ICDP_evaluation_summary_vol3.pdf.
36. Upton P, Davey R, Evans M, Mikhailovich K, Simpson L, et al., Tackling Indigenous smoking and healthy lifestyle programme review: A multi-criteria decision analysis. University of Canberra: Centre for Research and Action in Public Health; 2014. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-tis-hlp-review.
37. Australian Department of Health. Tackling Indigenous smoking. 2015. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/indigenous-tis-lp