Seeking a comprehensive approach to tobacco control for Aboriginal and Torres Strait Islander people

Tobacco smoking among Aboriginal and Torres Strait Islander people (hereafter we use the term “Aboriginal” to refer to both Aboriginal and Torres Strait Islander peoples, but do so with respect for the autonomy of the two peoples) is the leading cause of health inequities in this population, and its control is essential to “closing the gap” in health status between Aboriginal and other Australians.1 Australia, however, currently lacks a comprehensive framework that guides and monitors the effectiveness of tobacco control efforts among Aboriginal people at the local, state and national levels.

In a recent Australian study, the mortality rate for smokers over 45 years of age was three times higher than for non-smokers, and they died about 10 years earlier; two-thirds of deaths among smokers could be attributed to their smoking2 — and smoking accounts for 20% of all Aboriginal mortality.3 While smoking rates among Aboriginal people are decreasing, 42% of those aged 15 years or older reported smoking daily in 2012–2013 — more than 2.6 times the rate for other Australians.3 Of particular concern is that 39% of young Aboriginal people aged 12–24 years reported smoking daily,4 compared with 11% of young non-Aboriginal people.5 These data provide an insight into the substantial health gains that could be achieved were smoking rates among Aboriginal people reduced to the levels for non-Aboriginal Australians.1

“Talking About The Smokes”

The Talking About The Smokes (TATS) project for Aboriginal people complements recent efforts6-8 to tackle the problem of smoking in Aboriginal communities. The TATS project is a national collaborative study involving 34 Aboriginal community-controlled health services (ACCHSs), with over 2500 participants and 645 staff involved in 2012 and 2013. As part of the International Tobacco Control Policy Evaluation Project under the World Health Organization Framework Convention on Tobacco Control (FCTC), the TATS project aims to assess the impact of specific policies on smoking behaviour and attitudes. The TATS project found high levels of local knowledge about the risks of smoking.9 Most Aboriginal people who smoke wanted to quit,10 and about 70% had actually tried to quit. Aboriginal people in disadvantaged areas were less likely than others to want to quit,11 and many disadvantaged smokers who tried relapsed after a short time.12

The TATS project has highlighted the role of stress as a key driver of smoking behaviour among Aboriginal people.10 It led researchers to suggest that anti-tobacco messages be reframed to emphasise protecting others from passive smoke exposure, and that sustained targeted anti-tobacco advertising be ensured to reduce the social acceptability of smoking.13 The study has called attention to the importance of the role played by local community leaders as opinion leaders,14 the commitment of ACCHSs to reducing smoking,15 the role of health professional advice,11 and the need to improve access to nicotine replacement therapies.16 In particular, the TATS project emphasises the importance of broad comprehensive approaches to reducing exposure to passive smoke17 and to fighting causes of stress, such as poverty and racism.12

The TATS project provides important evidence about smoking behaviour and attitudes, and highlights the need for a broad approach to ensure the development of shared and consistent local, statewide and national strategies for reducing the high rates of smoking among Aboriginal people.12 The FCTC, endorsed by the National Preventative Health Taskforce,18accentuates upstream factors, such as regulating the exposure, costs and advertising of tobacco, as well as raising awareness and promoting effective quit programs.

Strategies for tobacco control

The United States Centers for Disease Control (CDC) has provided additional elements that could be adapted to establish a comprehensive framework for Aboriginal people in its Best practices for comprehensive tobacco control programs.19 The CDC guidelines focus on preventing smoking initiation in youths and young adults, promoting quitting, eliminating exposure to second-hand smoke and addressing tobacco-related disparities between different population groups. These aims are to be achieved through five overarching strategies:

• State and community interventions that encourage and support tobacco-free norms, such as restrictions on marketing, smoking and sales, as well as reducing exposure to second-hand smoke by expanding smoke-free public spaces and workplaces.
• Mass-reach health communication interventions that are sustained, targeted and culturally appropriate, and which reduce the number of young people who start smoking. The TATS project suggests these programs could involve community leaders, like programs developed in the Tackling Indigenous Smoking project.
• Cessation interventions that provide culturally appropriate psychological support and take into account the critical role of stress, and which ensure access to effective pharmacological treatments and continuing support to prevent relapse.
• Ongoing surveillance and evaluation, which is vital to ensuring programs are effective and modified as needed.
• Considerable funding for infrastructure administration and management to sustain current successes and to implement further effective interventions. Current financial constraints create challenges for sustaining comprehensive tobacco control programs, with important programs having already lost funding.

A comprehensive framework to guide tobacco control could be used to pinpoint gaps in current and past strategies, as well as to identify areas for future research, policy and program development. This could include 3- to 5-year smoking strategies developed collaboratively with Indigenous leaders, ACCHSs and services at local, state3 and national levels, where efforts will be required over decades to reduce the pernicious impacts of smoking on Aboriginal health.