With the Commonwealth Government’s National Preventive Health Strategy due for finalisation in the coming months, Dr Raglan Maddox, Professor Tom Calma AO, Dr Katherine Thurber and Associate Professor Raymond Lovett consider the opportunity to improve Aboriginal and Torres Strait Islander health outcomes through a renewed urgent focus on tobacco use.
The near-final draft of the National Preventive Health Strategy was released last week. After nearly two years of work, this document provides a long-term vision for improving the health of all Australians, and especially Aboriginal and Torres Strait Islander peoples. Driven by the Strategy, government decisions must stimulate a systemic shift to balance treatment and prevention, and will be underpinned by strong research evidence.
Nowhere is this more important than in the ongoing fight against tobacco-driven diseases and deaths. If you think the fight against tobacco is somehow already won, think again. Tobacco continues to be the single largest contributor to Aboriginal and Torres Strait Islander morbidity and mortality. It is very welcome that the draft Strategy demonstrates a focus on tobacco control, linked to the related and more specific National Tobacco Strategy, that is also being revised.
Here are the latest data. In 2018/19, one-third of Aboriginal and Torres Strait Islander adults had never smoked. The remaining two-thirds of adults were either current tobacco smokers (40% smoke daily and 3% smoke less frequently) or past smokers (24%). This constitutes over 300,000 adults at risk of smoking-related morbidity and mortality.
The Aboriginal and Torres Strait Islander smoking epidemic is distinct from the non-Indigenous smoking epidemic. Examples of where the epidemic diverges is that smoking prevalence is similar among males and females in the Aboriginal and Torres Strait Islander population, and that the epidemic has been protracted. New evidence demonstrates that we have previously underestimated smoking’s impact on the Aboriginal and Torres Strait Islander population. Smoking causes almost twice as many deaths as we previously realised. We now know that smoking causes more than one-third of all Aboriginal and Torres Strait Islander deaths at any age, causing over 10,000 deaths among Aboriginal and Torres Strait Islander peoples in the last ten years. Focusing on older adults, we see that smoking causes half of Aboriginal and Torres Strait Islander deaths at age 45 years and over.
The deadly news is that there is even more potential than we realised to improve health outcomes by reducing tobacco use. The National Preventive Health Strategy therefore has even greater potential than we realised, and we need to get it right.
Our current evidence-based knowledge demonstrates the urgent need to develop:
- interim targets specific to the Aboriginal and Torres Strait Islander population within the Long Term National Health Plan target of reducing smoking prevalence in the total Australian population to below 10 per cent by 2025, and
- specific smoking prevalence targets for Aboriginal and Torres Strait Islander adults in major cities, regional areas, and remote areas, in addition to the overarching target for the whole Aboriginal and Torres Strait Islander adult population, in order to accurately reflect diverse needs and trends in tobacco use.
The recent publication of a study of smoking and mortality for Aboriginal and Torres Strait Islander peoples in the International Journal of Epidemiology, and the associated factsheet, provided timely insight into the actual impacts of tobacco use for this population. Aboriginal and Torres Strait Islander specific evidence needs to inform appropriate prioritisation of tobacco control in current policy documents such as the implementation plan for the National Aboriginal and Torres Strait Islander Health Plan and the National Preventive Health Strategy.
While there has been a significant decline in tobacco use over the last 15 years with almost 50,000 fewer Aboriginal and Torres Strait Islander adult daily smokers today compared to if smoking prevalence had remained at 2004/05 levels, there is substantial room for improvement.
The next iteration of the National Tobacco Strategy – the last 2012-18 Strategy now having ended more than two years ago – simply must accelerate improvements in outcomes, including for Aboriginal and Torres Strait Islander peoples.
We know that tobacco policy measures can work. National implementation of ongoing tobacco reduction programs and policies across Australia, such as the Tackling Indigenous Smoking program (which currently only reaches part of the population), will help reduce smoking prevalence and prevent premature deaths.
As the 2020 Review of tobacco use among Aboriginal and Torres Strait Islander peoples highlighted, programs that are likely to be the most successful in reducing tobacco use are those that provide multiple supports to be smoke free at the individual, community and legislative level. We need a suite of culturally safe, holistic approaches that address the social determinants of tobacco use informed by the strongest available evidence specific to Aboriginal and Torres Strait Islander peoples. This should include a range of health care options and education at the individual and community level to support Aboriginal and Torres Strait Islander peoples to be smoke free.
Building the evidence
We need to keep accumulating more evidence about what works best to reduce smoking and preventing people taking it up. There are two broad directions for further research in (1) demonstrating what works and (2) how to improve monitoring and reporting. These have been previously outlined in A review of evidence on the prevalence of and trends in cigarette and e-cigarette use by Aboriginal and Torres Strait Islander youth and adults and the Review of tobacco use among Aboriginal and Torres Strait Islander peoples.
Based on the available research, there is an urgent need to better balance treatment and prevention. This includes Aboriginal and Torres Strait Islander specific research. Given the magnitude of preventable tobacco-related death and disease, there is a clear need for sustained and adequate funding – such as the “Preventive Health Future Fund” recently proposed by PHAA – to support the needs of Aboriginal and Torres Strait Islander peoples and tobacco control. As the title of the PHAA proposal says, we need to build a healthier future.
Building a healthier future
There is no silver bullet or one-size-fits-all approach to reducing tobacco use. It is a major public health issue that requires targeted and context-specific interventions and policies. All Aboriginal and Torres Strait Islander peoples have the right to access appropriate tobacco reduction programs and policies. Indeed, all Australians have a right to better health outcomes. Australia is a party to the World Health Organization’s Framework Convention on Tobacco Control (FCTC), an evidence-based treaty that reaffirms the right of all people to the highest standard of health, and highlights the need to engage Indigenous peoples in the development, implementation and evaluation of tobacco control.
The National Preventive Health Strategy, the imminent new Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan, as well as jurisdictional tobacco strategies, all need to be informed by the strongest available evidence to urgently address the tobacco epidemic. This will accelerate improvements in health outcomes and assist to inform tobacco control programs and policies, while helping to ensure equitable access to public health, health promotion and cessation programs and policies for all Aboriginal and Torres Strait Islander peoples across this diverse country.
The health and wellbeing of Aboriginal and Torres Strait Islander peoples, and future generations, is critically important. There are many existing strengths to build on, including proven policy and effective Aboriginal and Torres Strait Islander-run service delivery. But governments need to act decisively, and never lose sight of the best public health policy and investment: prevention.
Dr Raglan Maddox, Modewa Clan, National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University
Dr Katherine A. Thurber, National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University
Professor Tom Calma AO, Elder, Kungarakan tribal group and a member of the Iwaidja tribal group, University of Canberra
Associate Professor Raymond Lovett, Wongaibon, (Ngiyampaa), National Centre for Epidemiology and Population Health, Research School of Population Health, The Australian National University