Author Dr Penny Abbott
Expert reviewers Dr Rowena Ivers, Associate Professor David Thomas
Aboriginal and Torres Strait Islander people over the age of 15 years are twice as likely to smoke as their non-Indigenous counterparts, with 45% self reporting as current daily tobacco smokers in 2008.7 Sixty-eight percent of Aboriginal and Torres Strait Islander children aged 0–14 years live with a smoker.8,9 With such high prevalence rates, the use of tobacco is a major preventable cause of premature mortality and morbidity among Aboriginal and Torres Strait Islander people.9–11 Factors contributing to these high smoking rates include past government policies where tobacco was included in rations and in lieu of pay, socioeconomic disadvantage, high levels of community acceptance of smoking and lack of access to adequately resourced tobacco control interventions.10,12,13
Those at higher risk of developing smoking related complications include those with diabetes and other cardiovascular risk factors, pregnant women, those with a mental illness and those with other chemical dependencies.14 Tobacco smoking was calculated to be responsible for one-fifth of the total deaths of Aboriginal and Torres Strait Islander people in 2003, with particularly high mortality rates due to ischaemic heart disease, chronic obstructive pulmonary disease and lung cancer.11 Smoking in pregnancy is linked to poorer perinatal and child health.9 Exposure to environmental tobacco smoke is also a significant cause of mortality and morbidity and children are particularly sensitive to its effects.15,16
Tobacco dependence can be related to marijuana use. Young people can initially become dependent on tobacco from mixing it with cannabis. Cannabis addiction may complicate efforts to quit smoking tobacco.17 (See Chapter 3: The health of young people.)
Smokeless tobacco, including native tobaccos such as pituri, has been a historic form of nicotine delivery in Aboriginal and Torres Strait Islander communities. The tobaccos are chewed or pasted inside the mouth. There has been little research into the modern day use or effects of smokeless tobacco in Aboriginal and Torres Strait Islander communities, though this is still practised, particularly in central Australia.18,19
Health practitioners play a vital role in the prevention of smoking and the reduction of adverse health effects from smoking. All smokers should be advised to stop smoking and all interested smokers should be offered support to do so.20 General practitioners are advised to incorporate risk factor assessment and preventive health interventions within normal consultations whenever possible and at least annually. Such interventions are likely to involve management of multiple risk factors including smoking.21,22 There is strong evidence for the effectiveness of brief advice, brief interventions, cessation counselling, proactive quitlines and pharmacotherapy in increasing quit rates in general populations. Although there are relatively few interventions assessing the effectiveness of these interventions for Aboriginal and Torres Strait Islander people, there is no evidence to suggest these interventions are any less effective.10,12,23
Brief advice to quit has a small but significant effect on cessation rates. Assuming an unassisted quit rate of 2–3%, brief advice can increase quitting by a further 1–3%.24 Brief advice to stop smoking, which can be done in as little as 30 seconds, probably works mainly by motivating a quit attempt and seems to have its greatest effect in less dependent smokers.14,20,24 More effective than brief advice alone is a ‘brief intervention’ delivered by a health professional, which typically lasts 5–10 minutes. There are many frameworks for the structure of brief interventions, including the commonly recommended 5As: ask, assess, advise, assist, arrange (see the introduction to this chapter).20,21,25 Typical brief intervention activities include screening, providing brief advice, counselling techniques such as motivational interviewing, and recommending specialist support and/or pharmacotherapy as required. There is a dose-response effect to these intervention activities: the longer the duration of the person-to-person intervention the more effective it is.26 There is no evidence that any particular behaviour change method is more effective than another, but the basic principles of setting a quit date, emphasising the importance of abstinence and providing multisession support (preferably four or more sessions) are important.20,26 Relapse prevention advice for quitters in the first year after smoking cessation is recommended;4,26 however there is insufficient evidence to recommend any specific relapse prevention interventions.20,27
Assessment of readiness to quit assists in planning treatment, and tailoring interventions according to whether the patient is willing or unwilling to quit is helpful.26 Traditionally patients have been classified into the following stages of readiness to quit: pre-contemplation, contemplation, preparation, action and maintenance.14 However, there is no evidence the stages of change model is any more useful in smoking cessation than any other approach and should not limit health professionals from using interventions such as motivational interviewing for people who profess unwillingness to quit.20,26,28 Smoking cessation advice should be sensitive to the patient’s preferences, needs and circumstances. Factors consistently associated with higher abstinence rates are high motivation, readiness to quit, moderate to high self efficacy, supportive social networks and lower nicotine dependence. The Fagerström test for nicotine dependence is a validated measure for assessing nicotine dependence and may be useful in predicting relapse to smoking and guide a clinician on the intervention needed (see Resources).14,22,28
Flexible and culturally targeted modes of delivery of smoking cessation interventions are likely to be important to, and improve their effectiveness for, Aboriginal and Torres Strait Islander people.12,13,30 The effect of training health professionals to give cessation advice appears to be modest in reducing smoking rates on an individual basis but on a population health level it is effective.26 Treatment delivered by a range of health professionals increases tobacco cessation rates.20,26 At the health service level, instituting a practice system designed to identify and document tobacco use, such as a clinic screening systems and the use of computer prompts, almost doubles the rate of health professional intervention and results in higher rates of cessation.14,26
Referral to quitlines should be strongly considered for all smokers. There is conflicting evidence of their effectiveness in Indigenous or minority communities; however quitlines have been shown to be effective in many populations worldwide and are likely to be beneficial for Aboriginal and Torres Strait Islander people.10,12,20,21,23,26,30
Self help materials are defined as resources provided to an individual unaccompanied by any intervention provided by a health practitioner. They may be written, internet based or other media. Self help resources appear to have a small effect in increasing quit rates compared to no intervention.31,32 There is no current evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional or nicotine replacement therapy (NRT). Tailoring of materials increases their benefit.31 Aboriginal and Torres Strait Islander people are likely to prefer resources that are targeted and relevant to their community.10
Pharmacotherapies increase the effectiveness of smoking cessation counselling and should be offered to all smokers who wish to quit, except those in whom there are medical contraindications or insufficient evidence of effectiveness, such as pregnant women, light smokers and adolescents.20,26,30 Nicotine replacement therapy doubles the rate of successful quit attempts. Bupropion and varenicline triple the rate of success, but have a greater side effect profile than NRT.26,33 Varenicline and bupropion are not recommended for use in pregnancy; NRT can be considered during pregnancy after discussion of the risks and benefits.30
Smoking cessation counselling has been shown to be effective for adolescents,26 but there is a lack of clear evidence as to the specific interventions of most use in this group. It is recommended that interventions that are known to be effective in adults are also offered to adolescents.20 There is still a lack of evidence as to the effectiveness of school education programs in reducing the uptake of smoking.34 There are several as yet unevaluated school education programs that have been developed for Aboriginal and Torres Strait Islander children and adolescents.10 Computer and internet cessation programs are potential vehicles for smoking cessation programs for young people.14,32 Multicomponent community interventions appear to have some effect in reducing uptake of tobacco use in young people.35 Mass media campaigns can prevent the uptake of smoking by young people and work best when combined with broader tobacco control measures such as restricting adolescents’ access to tobacco.30,36,37
Environmental tobacco smoke (ETS), or secondhand smoke, causes asthma, ischaemic heart disease, COPD and lung cancer in non-smokers and is linked to multiple other diseases.38 Children are particularly susceptible to ETS, of particular importance given the high rates of ETS exposure for Aboriginal and Torres Strait Islander children both in utero and after birth.39 Intensive efforts to reduce children’s exposure to secondhand smoke are required and may include parental education and legislative initiatives.15,40
Public health initiatives are important in reducing smoking prevalence. Broad initiatives, such as raising standards of living and improving educational and employment opportunities, are critical to reducing smoking and the harm it causes for Aboriginal and Torres Strait Islander people.10,12,14,41 Multicomponent smoking cessation interventions are likely to increase abstinence rates and should be encouraged.6,20,26 This includes key public health initiatives such as price increases and taxation, restricting tobacco industry marketing, smokefree regulations (smoking bans), particularly in workplaces, and mass media campaigns.15,38,42
Recommendations: Primary prevention
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||People aged ≥10 years
||Smoking status should be assessed for every patient over 10 years of age on a regular basis
||Opportunistic and as part of an annual health assessment
||A system for identifying all smokers and documenting tobacco use should be used in every health service
||As part of a systematic health service approach
|Assess the level of nicotine dependence to help predict relapse to smoking and guide intervention choice (eg. Fagerström test: see Resources)
||Advise non-smokers to limit their exposure to tobacco smoke, especially parents of babies, young children and pregnant women
Parents who smoke should be counselled not to smoke in the house or in a confined space such as a motor vehicle
Recommendations: Interventions for smokers
|Preventive intervention type||Who is at risk?||What should be done?||How often?||Level/strength of evidence|
||All patients who smoke, regardless of the amount they smoke and whether they express a desire to smoke or not, should be offered brief cessation advice at every visit (consider using the 5As framework – see Chapter 1: Lifestyle, introduction)
||Opportunistic at every visit and as part of an annual health assessment
|Brief interventions should be adapted to local cultural setting (see Resources: SmokeCheck)
|Smoking cessation counselling should be offered to all people at every opportunity, and if possible, should comprise at least four face-to-face or group support sessions
|Consider referral to a proactive smoking cessation telephone service such as a quitline, particularly for people with limited access to face-to-face counselling
|Make available tailored self help quit smoking materials, both print and electronic
|People who have stopped smoking in the past year
||Offer follow up visits for smokers attempting to quit
||Within 1 week of quitting
Then within 1 month of abstinence
Then opportunistic for at least
|Pregnant women who are current smokers
||Offer intensive smoking cessation counselling (see Chapter 9: Antenatal care, for detailed recommendations)
||Recommend smoking cessation pharmacotherapies to patients interested in quitting. First line treatments are NRT, bupropion and varenicline
|Pregnant women may be offered NRT if the benefits outweigh the risks (see Chapter 9: Antenatal care)
||Complement the above individual based strategies with a community based approach to tobacco control (eg. promotion of smoke free workplaces)
|Promote training of Aboriginal and Torres Strait Islander health workers in brief interventions for smoking cessation to increase quit rates
Educational and quitting resources (Centre for Excellence in Indigenous Tobacco Control)
Tobacco in Australia: a comprehensive review of the major issues in smoking and health in Australia (Cancer Council Victoria)
Fagerström nicotine dependency test
Detailed information on tobacco resources, publications, programs and projects (Australian Indigenous HealthInfoNet)
Brief intervention and self help resources to promote smoking cessation for Aboriginal people (SmokeCheck)
Medicines to help Aboriginal and Torres Strait Islander people stop smoking: a guide for health workers
Medicines to help you stop smoking: a guide for smokers
Email IndigenousTobacco@health.gov.au for a copy
Supporting smoking cessation: a guide for health professionals (RACGP)
National Tobacco Campaign including ‘Break the Chain’ campaign for Aboriginal and Torres Strait Islander people and Quitline (proactive telephone support) information and referral forms (Australian Government)
Closing the Gap clearinghouse (AIHW)
Quitting resources (NSW Health)
Internet smoking cessation programs and resources
National youth smoking website
- Goldstein MG, Whitlock EP, DePue J. Multiple behavioral risk factor interventions in primary care: Summary of research evidence. Am J Prev Med 2004;27(Suppl 2):S61–79.
- The Royal Australian College of General Practitioners. SNAP – a population health guide to behavioural risk factor in general practice. Melbourne: The RACGP, 2004.
- Dosh SA, Summers Holtrop J, Torres T, Arnold AK, Baumann J, White L. Changing organizational constructs into functional tools: an assessment of the 5As in primary care practices. Ann Fam Med 2005;3 (Suppl 2):S50–2.
- Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, cat. no. 4714.0. Canberra: ABS, 2008. Cited October 2011. Available at www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0.
- Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey, 2004–2005, cat. no. 4715. Canberra: ABS, 2006.
- Australian Bureau of Statistics, Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2008, ABS cat no. 4704.0. Canberra: ABS, 2008. Cited October 2011. Available at www.aihw.gov.au/publications/ index.cfm/title/10583.
- Ivers R. Anti-tobacco programs for Aboriginal and Torres Strait Islander people. Canberra: Department of Health and Ageing, 2011.
- Vos T, Barker B, Stanley L, Lopez AD. The burden of disease and injury in Aboriginal and Torres Strait Islander peoples 2003. Brisbane: School of Population Health, The University of Queensland, 2007.
- Power J, Grealy C, Rintoul D. Tobacco interventions for Indigenous Australians: a review of current evidence. Health Promot J Austr 2009;20(3):186–94.
- Johnston V, Thomas DP. What works in Indigenous tobacco control? The perceptions of remote Indigenous community members and health staff. Health Promot J Austr 2010;21(1):45–50.
- Department of Health and Ageing. Smoking cessation guidelines for Australian general practice. Canberra: Commonwealth of Australia, 2007. Cited October 2011. Available at www.racgp.org.au/your-practice/guidelines/smoking-cessation/
- Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst Rev 2010;Apr 14;(4):CD005992.
- National Institute for Health and Clinical Excellence. Quitting smoking in pregnancy and following childbirth. PH26. London: National Institute for Health and Clinical Excellence, 2010. Cited October 2011. Available at www.nice.org.uk/guidance/ PH26/guidance.
- van Beurden EK, Zask A, Passey M, Kia AM. The mull hypothesis: is cannabis use contributing to high tobacco use prevalence among young North Coast males? NSW Public Health Bull 2008;19(3–4):72–4.
- Ratsch A, Steadman KJ, Bogossian F. The pituri story: a review of the historical literature surrounding traditional Australian Aboriginal use of nicotine in Central Australia. J Ethnobiol Ethnomed 2010,6:1–32.
- Northern Territory Department of Health. Alcohol and other drugs. The Public Health Bush Book. Darwin: Northern Territory Government, 2007.
- Ministry of Health. New Zealand smoking cessation guidelines. Wellington: Ministry of Health, 2007.
- The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (red book), 7th edn. Melbourne: RACGP, 2009. Cited October 2011. Available at www.racgp.org.au/your-practice/ guidelines/redbook/.
- Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet 2008;371(9629):2027–38.
- Digiacomo M, Davidson P, Abbott P, Davison J, Moore L, Thompson S. Smoking cessation in indigenous populations: elements of effective interventions. Int J Environ Res Public Health 2011;8:388–410.
- Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008;Apr 16;(2):CD000165.
- Clifford A, Pulver LJ, Richmond R, Shakeshaft A, Ivers R. Brief intervention resource kits for Indigenous Australians: generally evidence-based, but missing important components. Aust NZ J Public Health 2010;34(1).
- Fiore MC, Jaen CR, Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence 2008 update: clinical guideline. Rockville, MD: US Department of Health and Human Services, 2008. Cited October 2011. Available at www.ncbi.nlm.nih.gov/ books/NBK12193/.
- Lancaster T, Hajek P, Stead LF, West R, Jarvis MJ. Prevention of relapse after quitting smoking: a systematic review of trials. Arch Intern Med 2006;166(8):828–35.
- National Institute for Health and Clinical Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. PH1. London: National Institute for Health and Clinical Excellence, 2006. Cited October 2011. Available at http://guidance.nice.org.uk/PH1.
- Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for nicotine dependence: a revision of the Fagerström tolerance questionnaire. Br J Addict 1991;86:1119–27.
- National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. PH10. London: National Institute for Health and Clinical Excellence, 2008. Cited October 2011. Available at www.nice.org.uk/ nicemedia/live/11925/39596/39596.pdf.
- Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database Syst Rev 2005;Jul 20;(3):CD001118.
- Civljak M, Sheikh A, Stead LF, Car J. Internet-based interventions for smoking cessation. Cochrane Database Syst Rev 2010;Sep 8;(9):CD007078.
- Singh S, Loke YK, Spangler JG, Furberg CD. Risk of serious adverse cardiovascular events associated with varenicline: a systematic review and meta-analysis. CMAJ 2011;183(12):1359–66.
- Thomas RE, Perera R. School-based programmes for preventing smoking. Cochrane Database Syst Rev 2006;Jul 19;(3):CD001293.
- Sowden AJ, Stead LF. Community interventions for preventing smoking in young people. Cochrane Database Syst Rev 2003(1):CD001291.
- National Institute for Health and Clinical Excellence. Preventing the uptake of smoking by children and young people. PH14. London: National Institute for Health and Clinical Excellence, 2008. Cited October 2011. Available at http://guidance.nice.org.uk/PH14.
- Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database Syst Rev 2005;Jan 25;(1):CD001497.
- Scollo MM, Winstanley MH. Tobacco in Australia: facts and issues. Melbourne: Cancer Council Victoria, 2008. Cited October 2011. Available at www.tobaccoinaustralia.org.au.
- Australian Centre for Asthma Monitoring. Asthma in Australia 2008. Canberra: Australian Institute of Health and Welfare, 2008.
- Priest N, Roseby R, Waters E, Polnay A, Campbell R, Spencer N, et al. Family and carer smoking control programmes for reducing children’s exposure to environmental tobacco smoke. Cochrane Database Syst Rev 2008;Oct 8;(4 ):CD001746.
- Thomas DP, Briggs V, Anderson I, Cunningham J. The social determinates of being an Indienous non-smoker. Aust NZ J Public Health 2008;32(2):110–6.
- Stewart HS, Bowden JA, Bayly MC, Sharplin GR, Durkin SJ, Miller CL, et al. Potential effectiveness of specific anti-smoking mass media advertisements among Australian Indigenous smokers. Health Educ Res 2011;26(6):961–75.
- US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009;150(8):551–5.
- Piper ME, McCarthy DE, Baker TB. Assessing tobacco dependence: a guide to measure evaluation and selection. Nicotine Tob Res 2006;8:339–51.
- US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General—executive summary. Rockville, MD: Centers for Disease Control and Prevention, US Department of Health and Human Services, 2006. Available at www.surgeongeneral.gov/library/ secondhandsmoke/report/executivesummary.pdf.
- Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 2005;Apr 18;(2):CD001292.
- Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev 2009;Jan 21;(1):CD003999.
- Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Guideline No. 101, 2009. Cited October 2011. Available at www.sign.ac.uk/pdf/sign101.pdf.
- Flenady V, New K, MacPhail J. Clinical practice guideline for smoking cessation in pregnancy. Brisbane: The Centre for Clinical Studies, Mater Health Services, 2005. Cited October 2011. Available at www.stillbirthalliance.org.au/ doc/ Guideline_for_Smoking_Cessation_in_Pregnancy.pdf.
- Ivers RG, Castro A, Parfitt D, Bailie RS, D’Abbs PH, Richmond RL. Evaluation of a multi-component community tobacco intervention in three remote Australian Aboriginal communities. Aust NZ J Public Health 2006;30(2):132–6.
- Thomas D, Johnston V, Fitz J. Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory ‘Tobacco Project’. Aust NZ J Public Health 2010;34(1):45–9.