Christina Heris and David Thomas
Following a history of being paid or provided with rations of tobacco, smoking is the leading preventable cause of illness and death amongst Aboriginal and Torres Strait Islander people.
Historically, Aboriginal and Torres Strait Islander people start smoking at a young age, and a study just released looks at the trends in youth tobacco use to help inform prevention policies and programs.
The results make this a good news story. Most Aboriginal and Torres Strait Islander students are now never smokers, with steady falls in the number of teenagers taking up smoking observed. This means there are greater numbers of young Aboriginal and Torres Strait Islander people with healthier lungs and improved wellbeing – an important step towards Closing the Gap. There is, however, still much work to be done.
A sustained, comprehensive and targeted approach
Since the early 1970s Australia has implemented a comprehensive multi-layered approach to tobacco control which has included price measures, standardised packaging including graphic health warnings, smoke-free legislation, advertising and sponsorship restrictions and social marketing campaigns.
For the past decade, the Tackling Indigenous Smoking program specifically targeted at Aboriginal and Torres Strait Islander people has been implemented and the results are showing a significant decline across all age groups.
The declines in daily smoking prevalence among Aboriginal and Torres Strait Islander adults have been remarkable (2004-05: 50%; 2018-19: 40%). There are also significant increases in never smoking levels for 15-24-year-olds (44% in 2002 to 56% in 2014-15).
There is even better news in the results amongst secondary students where never smoking has increased (2005: 49%; 2017: 70%) with corresponding declines in past month and past week smoking. Trends over time were similar for Aboriginal and Torres Strait Islander students as for all students with an 8-10% annual increase in never smoking.
The Australian Secondary School Students’ Alcohol and Drug Survey (ASSAD) is currently the only national data source on tobacco use among Aboriginal and Torres Strait Islander adolescents aged 12-14 years and the largest sample of adolescents aged 12-17 years.
Reliable statistical data is crucial to measure the relative success of changes in prevention policies and programs. Using standard methods and measures since 1984, ASSAD allows for analysis of smoking trends covering a period of substantial tobacco control policy change in Australia. Although school response rates to the national, triennial survey of self-reported tobacco, alcohol and other drug use among Australia’s secondary school students has been steadily declining from 63% in 2005 to 17% in 2017, the ASSAD remains as our best data source to build a picture of youth smoking.
Getting in early
As half of Aboriginal and Torres Strait Islander people aged 18-24 years who smoke started smoking daily when aged 15-18 years, and a quarter before age 15 years, further prevention of initiation and transition to establishing smoking is important to reducing tobacco-related health inequities with non-Indigenous Australians.
The first study to examine smoking trends among Aboriginal and Torres Strait Islander students aged 12-17 years, between 2005 and 2017, found it is increasingly likely these students never smoked a cigarette and were less likely to currently smoke.
Taken with previous findings, these results demonstrate continued decline in current (weekly) smoking over the past 20 years in both younger adolescents (aged 12-15 years, 1996: 27%; 2017: 19%) and older adolescents aged 16-17 years (1996: 44%; 2017: 18%). Encouragingly these declines have been accompanied by substantial increases in the proportion who have never smoked in the same period for both age groups (aged 12-15 years, 39% to 76%; aged 16-17 years, 22% to 55%).
Policies/programs on target
The steady decline in youth smoking is the result of more than two decades of comprehensive tobacco control in Australia, including significant investment in national marketing, graphic health warnings on packaging, increased smoke-free legislation, the introduction in 2012 of tobacco plain packaging, and annual excise increases from 2013.
Reduced health inequalities and reduced levels of smoking also follow the 2008 Council of Australian Governments’ (COAG) Closing the Gap Strategy and the target to halve the daily smoking rate among Aboriginal and Torres Strait Islander adults by 2018; along with targeted social marketing campaigns, the introduction of the Tackling Indigenous Smoking and Healthy Lifestyle Program in 2010, and its revised tobacco focused model in 2015, Tackling Indigenous Smoking.
Key study findings to inform future policy measures
There were two key findings from the study into smoking rates amongst Aboriginal and Torres Strait Islander secondary students which may inform future policy and program initiatives. These relate to price measures and the target age range and objectives for prevention interventions.
The first found the prevalence of heavier smoking started to decline in Aboriginal and Torres Strait Islander students around 2014. This period coincides with the introduction of tax-driven changes in cigarette prices, measures shown to reduce smoking and prompt quit attempts, including among young people and socially disadvantaged sub-groups.
Secondly, while the proportion of 12-17-year-old Aboriginal and Torres Strait Islander students who had ever experimented with cigarettes in 2017 had reduced to 30% from 50% in 2005, this still represents a substantial proportion of students at risk of regular smoking. Further, the quarter of 12-15-year-olds who had already tried smoking highlights the importance of the early secondary years for prevention.
The study found that in 2017, 18% of 16-17-year-olds were already smoking at least weekly. Youth prevention programs have a role to play in not only minimising transition to regular smoking, but also in providing age-appropriate quit support. While some young Aboriginal and Torres Strait Islander people do not perceive standard cessation supports to be relevant to them, ABS data shows an interest in quitting with more than a third of Aboriginal and Torres Strait Islander smokers aged 15-17 years having made a quit attempt.
There may be opportunities to deliver relevant prevention programs in community and/or school settings. While the evidence for school-based interventions is mixed, there are indications that programs that include a focus on developing self-efficacy skills and empowering young people are more likely to be effective than information-only programs.
Few national studies have examined smoking among Aboriginal and Torres Strait Islander people in early adolescence, a key period for smoking initiation. This study extends recent findings of increased never smoking and reduced smoking prevalence among Aboriginal and Torres Strait Islander adolescents and young adults, and the total ASSAD sample.
Although similar trends were found for both Aboriginal and Torres Strait Islander students and the total ASSAD sample, suggesting parallel policy impact across all students, current smoking remained substantially higher, demonstrating a persisting gap in smoking outcomes. Along with slower progress during periods of weaker tobacco control, continuing higher prevalence of smoking highlights the need for sustained greater investment to accelerate increases in never smoking and improve health equity. Also, supporting strengths-based Aboriginal community-controlled programs should remain a priority as part of comprehensive, population-wide strategies.
Christina Heris is a PhD candidate at the University of Melbourne with a background in health and science communication. While finalising her thesis on smoking prevention with Aboriginal and Torres Strait Islander adolescents, Christina is working with the CRE in Aboriginal Child and Adolescent Health (REACH) on training and research projects.
David Thomas leads the tobacco control research program at Menzies School of Health Research in Darwin. He has worked in Aboriginal and Torres Strait Islander health for more than 30 years. He was one of a small group who re-established the NT Branch of PHAA in the early 1990s, later serving as Branch President (1997-99).