There is good news to tell about Aboriginal and Torres Strait Islander tobacco control: smoking prevalence is falling and government funding has been secured in a climate of under-investment in prevention.
The Australian Government has committed to funding the Tackling Indigenous Smoking program until 2022. The program continues to fund 37 regional teams with a focus on localised health promotion. This localised activity has been supported by two national Indigenous mass-media campaigns, individual cessation advice provided by Aboriginal Community Controlled Health Organisations and via the Australian quit-smoking helpline, Quitline. But some state governments could do more to support Aboriginal and Torres Strait Islander tobacco control.
National Aboriginal and Torres Strait Islander smoking prevalence is falling, with significant falls in urban and regional areas where most Aboriginal and Torres Strait Islander people live. However, there has been little improvement in remote areas and this has become an area of future focus, with three additional Tackling Indigenous Smoking teams announced in remote areas in 2020.
We can celebrate the recent achievements of Aboriginal and Torres Strait Islander tobacco control and the current and emerging leaders who are ready for future challenges from the tobacco industry.
There is plenty of good news to tell about Aboriginal and Torres Strait Islander tobacco control. Most importantly, smoking prevalence is falling. In the 24 years to 2018–19, the national prevalence of current smoking fell from 55% to 43% among Aboriginal and Torres Strait Islander people aged 18 years and older.1,2 Smoking prevalence among young people and smoking initiation have declined, with greater declines in recent years.1,3 Successful cessation has also increased. In 2018–19, 36% of people who had ever smoked had successfully quit smoking, up from 24% in 2002.1,2 More children are being protected from second-hand smoke at home. In the 10 years to 2014–15, the proportion of children aged under 15 years living in homes where smoking occurred indoors has halved, from 28% to 13%.4,5 Fewer Aboriginal and Torres Strait Islander mothers are smoking in pregnancy (down from 52% in 2009 to 44% in 2017).6
However, more improvements are necessary. Smoking is estimated to be responsible for 12% of the total burden of disease experienced by Aboriginal and Torres Strait Islander people.7 The improvements in smoking outcomes have been largely in parallel with similar improvements among non-Indigenous Australians.1 The 30 percentage point gap in smoking prevalence has not narrowed in 20 years. Smoking is estimated to be responsible for 23% of the health gap between Indigenous and non-Indigenous Australians.7
In response to advocacy highlighting the improvements being achieved in Indigenous tobacco control and the further improvements required, the Australian Government last year invested $184 million to continue the Tackling Indigenous Smoking program for a further 4 years until 2022. This program grew out of the 2015 redesign of the Tackling Indigenous Smoking and Health Lifestyle program, which had started in 2010 and overlapped with the smaller Indigenous Tobacco Control Initiative, which was launched in 2008. Telephone Quitline cessation support services have been enhanced for Aboriginal and Torres Strait Islander people, and funding has allowed the Quitskills smoking cessation training program to be available nationally. Aboriginal and Torres Strait Islander people have been able to access cheaper nicotine replacement therapy and smoking cessation therapies varenicline and bupropion through the Closing the Gap Pharmaceutical Benefits Scheme Co-Payment Measure since 2010.
The majority of the Tackling Indigenous Smoking program funds have been spent on grants to 37 regional Tackling Indigenous Smoking teams. Almost all of these are based in Aboriginal Community Controlled Health Organisations (ACCHOs). Since the 2015 redesign of the program, these teams have increasingly concentrated on a population health approach rather than individual cessation support, with a focus on localised health promotion. The localised health promotion by regional Tackling Indigenous Smoking teams includes community events, local ‘community identities’–based marketing using broadcast and social media, the distribution of campaign material and merchandise, and the promotion of smoke-free spaces and events. These teams have reported that their work in building local support, trust and partnerships has been critical in their success.8 Other national research has shown that more smokers who recalled such localised advertising were motivated to quit and attempted to quit than those who did not recall seeing any advertising, with more limited results for mainstream campaigns.9,10 A new evaluation will investigate whether smoking outcomes are improving faster in areas with these teams than in areas without.
The first national Aboriginal and Torres Strait Islander antismoking mass media campaign, ‘Break the chain’, was launched in 2010, followed by a second, ‘Don’t make smokes your story’, in 2016. In contrast, Australian national expenditure on all antismoking television campaigns has been inadequate since 2013.11 The 2018 evaluation of ‘Don’t make smokes your story’ found high recognition by smokers and ex-smokers and continued positive responses about its perceived usefulness.12
All this health promotion activity complements the individual cessation support provided to smokers by ACCHOs. A national study found that more Aboriginal and Torres Strait Islander smokers recalled having been advised to quit by a health professional in the past year than a similar sample of all Australian smokers.13
In spite of the achievements in reducing smoking prevalence, securing government funding and implementing programs, challenges remain in Aboriginal and Torres Strait Islander tobacco control.
Although daily smoking prevalence in urban and regional areas – where 81% of Aboriginal and Torres Strait Islander people live – has fallen from 49% in 2004–5 to 37% in 2018–19, there has been no change in remote areas (52%).2,14 Similarly, there were no significant improvements from 1994 to 2014–15 in the proportion of people who had ever smoked and who had successfully quit smoking in remote areas, in contrast to the improvements in other areas.1 However, there are early signs of improvement. The same national surveys demonstrated increasing proportions of smokers in remote areas who reported having made a quit attempt in the past year (from 43% in 2008 to 58% in 2014–15). They also show similar promising improvements in remote and non-remote areas in youth smoking prevalence and initiation and in the protection of children from smoking inside homes.
Further improvements may follow from the increased intensity of tobacco control activities of Tackling Indigenous Smoking teams in remote areas, but there may also be a need for greater reach of tobacco control activities into remote areas not served by these teams. Similarly, there are also regional and urban areas without teams. In 2020, three additional Tackling Indigenous Smoking teams were announced in remote areas.
The Tackling Indigenous Smoking program started as part of the Australian Government’s contribution to the Council of Australian Government’s National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes in 2008. The Australian Government has shown clear leadership through its investment in the Tackling Indigenous Smoking program, however the contributions of state and territory governments have been patchy, and some could do much more.
Notably, the Northern Territory Government, the jurisdiction with the highest proportion of residents who are Indigenous (30%) and the highest Aboriginal and Torres Strait Islander smoking prevalence (49%), again won the Australian Medical Association and Australian Council on Smoking and Health’s Dirty Ashtray Award for the jurisdiction with the worst performance on tobacco control in 2019.15,16 The Northern Territory has ‘won’ the award 13 times since it started 25 years ago in 1994, and can do much more to improve its egregious record on Indigenous tobacco control. Similarly, while the Tackling Indigenous Smoking teams and ACCHOs are showing excellent leadership in their communities on tobacco control and smoke-free spaces, more work can still be done in partnership with leaders of other Aboriginal and Torres Strait Islander organisations.
We must never forget the culpability of the tobacco industry for the smoking epidemic and for its attempts to undermine tobacco control, however we can celebrate Aboriginal and Torres Strait Islander efforts of resistance. In 1984, the National Aboriginal Conference forced tobacco company WD & HO Wills to withdraw a racist advertisement for John Player Special cigarettes.17 However, similar complaints did not stop the offensive misrepresentations of Aboriginal people in European advertisements for Winfield cigarettes.17 A 1994–95 Senate Inquiry heard complaints from the Northern Territory Government that multinational tobacco company Philip Morris was promoting sales in remote Aboriginal communities with free t-shirts with the community’s name and Marlboro cigarettes colours and design.17
Philip Morris has now been caught out again targeting Aboriginal organisations, sending unsolicited letters to Aboriginal organisations promoting the legalisation in Australia of its heat-not-burn product IQOS in 2019.18 Similarly, Philip Morris has promoted free and half-price promotional trials of IQOS in Māori communities in Aotearoa New Zealand.19 The Philip Morris International funded Foundation for a Smoke-Free World has targeted Indigenous peoples through its funding of the ‘Centre for Research Excellence: Indigenous Sovereignty and Smoking’ in Auckland. However, Aboriginal and Torres Strait Islander leaders have joined with other Australian tobacco control researchers and Indigenous researchers from New Zealand, Canada and the US to call for others to reject funding from the Foundation, or any other tobacco industry funding.20,21
The achievements in Aboriginal and Torres Strait Islander tobacco control are among the most encouraging stories in Australian tobacco control and in efforts to improve Indigenous health and to Close The Gap between Indigenous and non-Indigenous Australians. The current and future Aboriginal and Torres Strait Islander leaders in tobacco control are ready for future challenges from the tobacco industry. They now stand in a prime position to support further declines in smoking prevalence across all Aboriginal and Torres Strait Islander communities.
Externally peer reviewed, invited.
© 2020 Thomas and Calma. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.