Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

vi - Indigenous Australians – contribute to 'Close the Gap'

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'We believe that initiatives targeting Indigenous Australians must be embedded within communities, using local knowledge, skills and expertise' (Quote from submission)

In the current context of high levels of chronic disease in Indigenous communities, obesity, tobacco and alcohol make significant contributions to the burden of illness, injury and disease in Indigenous communities.[77] The burden of ill health is not evenly shared by Indigenous Australians, with geographical distribution having a major influence. The majority of Indigenous Australians live in urban towns and cities (75%), as compared to those living in remote communities (25%). Reflecting this distribution, those living in urban areas constitute 60% of the health gap and therefore a greater burden of ill health, whereas the remaining 40% of the gap in health is attributed to those living in remote communities, usually with the greatest needs.[5]

The announcement of the 'Close the Gap' commitment by all Australian governments in December 2007 recognised the extent and urgency of the problem facing Indigenous Australians.[77] To be successful in reducing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation, the disparity in levels of sickness and death attributable to obesity, alcohol and tobacco must be addressed. Health inequity is intimately bound up with these processes.[78]

It is now known that a person's social and economic position in society, their early life experiences, their exposure to stress, their educational attainment and their employment status all exert a powerful influence on their health throughout life.[79] Social exclusion and the amount of control people have over their lives have been shown to be critical social determinants of health.[80-83]

The poor nutrition and lack of physical activity which contribute to obesity and the use of tobacco and alcohol are embedded in a complex social, historical and political context, marked by processes of intergenerational powerlessness, poverty and social exclusion. There is a strong association between obesity, tobacco and alcohol use and these social determinants of health.[79] Therefore, addressing the broader social determinants of health – including poverty, lack of education and social exclusion – is a critical element in a broader strategy to tackle obesity, tobacco and alcohol in the Indigenous community.

In the current context of high levels of chronic disease in Indigenous communities, obesity, tobacco and alcohol make significant contributions to the burden of sickness, injury and death in these communities. Together, these factors contribute to almost a quarter of the 'health gap'.[84]

The proportion of the health gap attributable to alcohol, tobacco and obesity is also distributed unevenly. While Indigenous people in remote areas make up 26% of the total Indigenous population, they contribute 34% of the total health gap attributable to tobacco, 38% of the health gap due to high body mass, and a full 50% of the health gap due to alcohol.[77]
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Impacts associated with obesity, tobacco and alcohol

Overweight and obesity

Overweight and obesity have been estimated as contributing to 11% of the total burden of injury and disease of Indigenous Australians, and is particularly associated with type 2 diabetes and ischaemic heart disease.[84] In 2004–05, 57% of Indigenous adults were overweight or obese, a significant increase from 1995 (48%).[86] Obesity and overweight is also an issue for Indigenous children.[95, 96]

Tobacco

'…need to take a large scale, more systematic approach to tackling tobacco in Indigenous communities rather than continuing to undertake small scale or pilot projects' (Quote from submission)

Tobacco smoking is the cause of 20% of deaths and 12% of the total burden of disease and injury in the Indigenous community, and is the major single contributor to ill health, predominantly through ischaemic heart disease, chronic obstructive pulmonary disease (COPD) and lung cancer.[84] A high proportion of Indigenous people smoke (around 50%),[89] compared to the Australian population as a whole (16.6%),[90] with smoking rates of up to 83% for men and 73% for women being recorded in some communities.[91]

There appears to have been minimal or no change in these rates, while the trends in smoking rates for Australia as a whole have been consistently downwards since the early 1970s.[92-94]

Alcohol

'…although Indigenous Australians are more likely to abstain from alcohol than non Indigenous Australians – those who do consume alcohol are more likely to drink at risky levels' (Quote from submission)

Alcohol is associated with 5% of the burden of disease and injury borne by Indigenous Australians, in particular through homicide, violence and suicide. For Indigenous men in particular, it is strongly associated with four of the top 10 causes of premature mortality: suicide (9.1% of potential years of life lost), road traffic accidents (6.2%), alcohol dependence and harmful use (3.9%), and homicide and violence (2.8%).[84]

Drinking while pregnant is also associated with Foetal Alcohol Spectrum Disorders (FASD), which are estimated as being between three and seven times more common in the Indigenous population.[85]
One in six Indigenous adults reports drinking in such a way as to pose a long-term high risk to their health, up from 13% in 2001; one in five (19%) reports short-term high-risk (or binge) drinking at least once a week.[86]

There is emerging evidence that alcohol is also making a major contribution to premature deaths from heart disease in Indigenous communities, consistent with the possible impact that binge drinking has had on cardiac deaths in Russia.[87, 88]
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Key principles for successful interventions[77]

  • Genuine local Indigenous community engagement to maximise participation, up to and including formal structures of community control.
  • Integration of targeted programs on alcohol, tobacco and obesity with broad-based comprehensive primary healthcare.
  • Ensuring programs are adequately resourced for evaluation and monitoring so they can contribute to intervention policy knowledge.
  • Evidence-based approaches that are reflective and that involve the local community in adapting what is known to work elsewhere to local conditions and priorities.
  • Adequate and secure resourcing to allow for actions to be refined and developed over time.
  • Performance indicators and measurement that are linked to accountability and action.

How can prevention help 'Close the Gap'?


Broad, multifaceted action is needed to address the contribution made by alcohol, tobacco and obesity to the health gap between Indigenous and non-Indigenous Australians. Specific programs addressing these issues need to be combined with broad action on the social determinants of health, and action to strengthen and extend health services, particularly comprehensive primary healthcare.

Primary healthcare has come to be recognised by policy makers, health professionals and the Indigenous community as the key strategy for improving the health of Indigenous Australians. To the extent that there have been health improvements, these have been credited to improved primary healthcare.[97] Even where measurable improvements are limited (for example, in chronic disease mortality rates), the conclusion has been drawn that while the social determinants continue to drive high levels of ill health, improved primary healthcare services are at least providing a brake on what would otherwise be accelerating mortality rates.[98]

A well-resourced and robust, comprehensive primary healthcare system is a critically important platform in order to deliver the full range of core services required under a comprehensive model of primary healthcare to 'Close the Gap', including that part of the health gap attributable to alcohol, tobacco and obesity.


Actions will need to provide:

  • Support and resourcing for community agency and action through the establishment of local community leadership groups.
  • Adequate long-term investment in social marketing campaigns to shift social norms of smoking and alcohol consumption amongst Indigenous people.
  • Smoke-free workplaces, community spaces and events, especially through work with Indigenous organisations and possibly through the employment of tobacco control workers in National Aboriginal Community Controlled Health Organisation (NACCHO) affiliates.
  • Resourcing of multi-component community-based programs, including effective and professional evaluation.
  • Robust antenatal, maternal and child health systems for Indigenous communities.
  • Effective screening, intervention and referral pathways in primary healthcare, and between primary healthcare and specialist services.
  • Reform and increased support for treatment and rehabilitation services for alcohol-related problems.
  • Actions on pricing of alcohol, including a broad review of Australia's alcohol taxation policy as part of a comprehensive approach to alcohol problems in Australia.
  • Restriction of alcohol supply, including the numbers and types of licenses and hours of sale, especially for takeaway licences.

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