|Last updated: August 2016
Suggested citation: van der Sterren, A, Greenhalgh, EM, Knoche, D, & Winstanley, MH 8.6 Smoking cessation and 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/8-6-cessation
The most recent informationi on smoker status (including information on ex-smokers and never smokers) is reported in the 2012–13 National Aboriginal and Torres Strait Islander Health Survey.1 These prevalence rates, adjusted for age so that they are comparable to the non-Indigenous population, are reported in Figure 8.6.1. Further analyses of smoking status data by age, sex, and Indigenous status are shown in Figure 8.6.2.
Age-standardised smoker status, Indigenous and non-Indigenous persons 15 years and over, 2012–13
*Current smoker includes daily, weekly and other current smokers
Source: ABS 20141 using data from the National Aboriginal and Torres Strait Islander Health Survey 2012–13 and the 2011–12 Australian Health Survey
In 2012–13, from ages 25–34 and older, Indigenous males were significantly less likely to be ex-smokers than non-Indigenous males. For women, there was only a significant difference in ex-smokers among those aged 35–44. These patterns are shown in Figure 8.6.2.
Proportion of ex-smokers by Indigenous status, sex, and age, 2012–13
Source: ABS 20141 using data from the National Aboriginal and Torres Strait Islander Health Survey 2012–13 and the 2011–12 Australian Health Survey
In 2012–13, a nationally representative sample of 2522 Aboriginal and Torres Strait Islander people from 35 locations across Australia were interviewed, which formed the baseline data for the Talking About The Smokes (TATS) Project. The TATS project aimed to provide a comprehensive evidence base for guiding practice and policy to reduce tobacco-related harm among Indigenous Australians. Questions regarding past quit attempts revealed that compared with the general population, fewer Aboriginal and Torres Strait Islander daily smokers had ever tried to quit, but a similar proportion had attempted to quit within the past year (Figure 8.6.3). Of those who had tried to quit in the past year, similar proportions reported sustaining their most recent quit attempt for one month or more (Indigenous, 31% v non-Indigenous, 33%) and six months or more (Indigenous, 10% v non-Indigenous, 11.7%).2
Comparison of tobacco-related behaviour modification among Aboriginal peoples and Torres Strait Islanders (daily smokers) and the general Australian population (daily smokers)
Source: Nicholson et al. (2015)2 using data from the Talking About The Smokes (TATS) Project and the Australian International Tobacco Control Policy Evaluation Project (ITC Project).
A consistent theme in many studies of Indigenous smokers is the roles of families and communities in motivating cessation. In the TATS project, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, and having support from friends and family were associated with wanting to quit.3 A 2010 national study investigating Indigenous smoking issues found that key motivators for smoking cessation were: the importance of family and kin, and the impact of smoking on them; supporting self-efficacy in the quitting process; the cost of smoking, particularly because it affects the family; and the adverse effects of smoking on sport and physical activity.4 Similarly, a qualitative study in 2008 found that the health and wellbeing of Indigenous people’s families was particularly important in motivating quit attempts; smokers cited protecting their children and family from the health consequences of secondhand smoke, acting as positive role models to their children, reducing the negative social and economic impacts that smoking was having on their family, and maintaining good health to fulfil their family responsibilities as reasons to quit smoking.5
Health concerns are also important determinants of cessation among Indigenous Australians. Participants in the TATS project cited worrying about future smoking-related health effects and believing quitting to be beneficial as reasons for wanting to quit.3 The National Aboriginal and Torres Strait Islander Tobacco Control Project (2001) found that among those who had successfully quit smoking, a main motivator was either suffering an illness or being diagnosed with a serious illness. Other reasons for quitting included wanting to live long enough to see their grandchildren grow up, a personal wish to quit, seeing others suffer sickness or dying from tobacco-related illnesses, the cost of tobacco, and their children asking them to give up. Quitters were more likely to have quit at a relatively early age (25 or younger). Half of quitters had done so ‘cold turkey’.6 Western Australian research on the smoking habits of urban Indigenous woman found that of those who had quit smoking, health concerns were cited as the main reason (49%), followed by pregnancy (12%).7 Similarly, motivators for quitting among a group of young urban Aboriginal South Australians included pregnancy and/or children and health reasons, as well as cost issues and sporting performance (for males).8
Research in 1999 evaluating the National Tobacco Campaign (1997–98) found that quitting was perceived as a very difficult goal among Indigenous people in Victoria, and the combination of smoking being strongly embedded in community norms, peer expectation to smoke, and the concomitant lack of social support for quitting discouraged quitting (see Section 8.9.1).9 Recent research has also found that perceiving quitting as very difficult is associated with being less likely to want to quit, as is enjoying smoking.3 Along with being an important motivator for quitting, families can also play a central role in initiation to smoking and maintaining the habit (see Section 8.9).5 In the National Aboriginal and Torres Strait Islander Tobacco Control Project (2001), the reasons most commonly given for returning to smoking after an attempt at quitting were succumbing to peer or family influences, stress, and addiction.6 The authors of a Western Australian study highlight that one of the key functions of smoking among urban Indigenous women is its role as a facilitator of friendship bonding and social cohesiveness. This strongly reinforces smoking behaviour and perceptions, and undermines likelihood of quitting, since to give up smoking is to risk social isolation and alienation.7
Smoking by Aboriginal and Torres Strait Islander women during pregnancy remains high (see Section 8.3), and several studies have investigated smoking behaviours in this group. In 2012, 11.6% of Aboriginal and Torres Strait Islander women who smoked during the first 20 weeks of pregnancy reported not smoking during the second 20 weeks of pregnancy, which was half that of non-Indigenous women (22.9%).10 Between 2005 and 2011, there was a statistically significant decline (of 6%) in smoking during pregnancy among Indigenous women, but this drop was much greater among non-Indigenous women (25%).11
Studies have found that women may report cutting down the number of cigarettes smoked in an attempt to limit risk to their baby.12,13 In a New South Wales study, 24% of women using tobacco at the beginning of their pregnancy quit, while about 51% decreased their tobacco use (13% stayed the same, and 12% increased their use).14 Among those who quit, a significant proportion may take up smoking again after the birth of the baby.13,15 A qualitative study in 2013 found that Indigenous women in NSW were aware of the dangers of smoking, felt guilty about smoking while pregnant, and tried to change their smoking behaviour, with many contemplating quitting; however, due to the difficulty of quitting, reducing consumption was more common.16 There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight17 and reduce preterm birth.18 However, Australian19 and UK20 guidelines state that health professionals should be recommending complete abstinence to pregnant women in order to maximise health benefits.
Two studies have found that pregnant Indigenous women may be more motivated and able to quit than smokers generally due to their status as mothers-to-be.21,22 Both studies found that nicotine dependence was generally low. One of the studies21 also involved investigating the ‘stages of change’ profiles of their participants, and found that 14% had taken action to give up (‘action’ stage), 55% were thinking about giving up (‘contemplation’ stage), and 31% were not thinking about giving up (‘pre-contemplation’ stage). Importantly, 45% of women had both low nicotine dependency and were thinking about giving up (‘contemplation’). The mean number of previous quit attempts for this sample was 1.4, with 15% having tried to quit more than 10 times.
Apart from the physical addiction, the barriers to quitting reported by pregnant women include: family pressure to continue smoking; using smoking as a way to manage difficult life circumstances and the related stressors (which were seen to increase during pregnancy); and the perceived social benefits of smoking, as an opportunity for ‘yarning’, relaxation and time out.12,13 Participants in the qualitative NSW study suggested that pregnant women might risk social isolation by quitting, as smoking plays such an important role in social cohesion. These findings might also help explain the higher likelihood of cutting down rather than quitting; this strategy allows Aboriginal pregnant women to feel socially connected, while also trying to minimise harm to their foetus.16 Indigenous women are also more likely to smoke during pregnancy if there are more smokers in the household,15,23 if they have a partner who smokes,23 and if they experience higher levels of daily stress.23 Tobacco action initiatives for pregnant Indigenous women are discussed in Section 184.108.40.206.
Studies on tobacco use among Aboriginal health workers have found that the majority of Aboriginal health workers wanted to quit, and/or had made at least one quit attempt in the recent past.6,24-26 A 2013 study of Aboriginal health workers in South Australia found that among current smokers (just over half the total sample), half had tried to quit in the past year, and over two-thirds demonstrated a readiness to quit. Successful quitters (about one quarter of the total sample) had the highest levels of perceived social support and part-time employment. Current smokers expressed lower emotional wellbeing compared with quitters and never smokers, and three times as many lived with another smoker.27 The TATS study found that staff of Aboriginal community-controlled health services who were smokers were more likely than smokers in their communities to have ever tried to quit, to have often noticed antismoking advertising, and to have used stop smoking medications, often with the support of their workplace. Ex-smokers were most likely to report being confident in talking to others about smoking and quitting. About three-quarters of smokers agreed that being a non-smoker sets a good example to patients, and most did not smoke with, or in front of, patients.28
Relieving stress, particularly stress associated with the job, is commonly cited as a reason for Aboriginal health workers to smoke.6,26-29 In a qualitative study in 2012, Aboriginal Health Workers described burdensome stress and grief as leaving them unable to prioritise quitting smoking. (However, smoking appears to increase stress, while quitting is associated with reduced stress—see Section 7.12.3). More broadly, the normalisation of smoking in Indigenous communities was an overarching barrier to cessation; smoking was often part of the workplace culture, and there were a lack of smokefree places and policies.30 Other barriers that have been reported are a lack of support, living/working in environments where smoking is common, having a partner who smokes, addiction, and withdrawal when trying to quit.26 Smoking among Aboriginal health workers may affect their capacity to deliver smoking cessation activities (see Section 8.10.5). Specific tobacco action programs targeting Aboriginal health workers are discussed in Section 220.127.116.11.
Smoking cessation behaviour among young Aboriginal and Torres Strait Islanders is discussed in Section 8.4. Attitudes and beliefs about smoking are discussed further in Section 8.9, and initiatives and policies designed to promote and support quitting among Aboriginal peoples and Torres Straits Islanders are discussed in sections 8.10 and 8.13 respectively. Smoking cessation is discussed in greater detail in Chapter 7.
i The prevalence rate for Indigenous current smokers reported here (45%) is different to that reported in Section 8.3 (47%). Here, the prevalence rate has been age-standardised to allow comparison to the non-Indigenous current smokers' rate.
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