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

Key action area 7: Work in partnership with Indigenous groups to boost efforts to reduce smoking and exposure to passive smoking among Indigenous Australians

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‘Reducing smoking prevalence among Indigenous Australians must be a high priority if the life expectancy gap is to be successfully closed’ (Quote from submission)

Tobacco use among Aboriginal and Torres Strait Islander peoples causes disturbing levels of ill health and premature death in infants, parents and elders, and is a major contributor to the life expectancy gap.[8] In New Zealand, smoking has declined by more than 20% in Maori men and women over the last four years.[172] In Australia, smoking among Indigenous people appears to have not declined at all over the past 15 years, although rates in remote communities may have improved slightly.

Figure 3.4:
Prevalence of smoking among Indigenous Australians aged 18+, in all areas 2001 and 2004–2005, and in non-remote areas 1989 to 2004–2005

(line= non-Indigenous)
Sources: ABS National Health Surveys 1989, 1995 and 2001, and Aboriginal and Torres Strait Islander National Health Survey 2004–2005

Shortly after its election, the Australian Government pledged $14.5 million over four years to help tackle smoking in Indigenous communities.[26] This has helped to get the issue on the Indigenous health agenda, and has resulted in a number of projects and initiatives. However, small pilot projects, no matter how well designed and run, will not make the inroads necessary to reduce smoking rates across the Indigenous population as a whole. While there is a place for trials of innovative new approaches, it is now time to scale up efforts, working closely with and through Indigenous organisations. Time and resources should be allowed for training and sharing of insights, and it should be acknowledged that quality of service will improve as staff become more experienced.

Learning through doing
‘…there is a need to include both Indigenous-specific activities, as well as measures to ensure access of Indigenous people and communities to mainstream programs and services’ (Quote from submission)

Evidence suggests that multi-component community-based projects developed and implemented by local communities, and involving strong local drivers, are likely to impact on Indigenous smoking. Community control of these projects and the involvement of influential local community members will have greater impact on de-normalising tobacco use and reducing the social acceptability of smoking. A mix of multiple strategies as determined by the local community will reinforce anti-smoking messages and provide a variety of options for families and individuals to address their tobacco use. Projects should be established in a variety of locations, and could be extensions of existing projects. Funding must sustain the projects over a period adequate to evaluate processes and possibly impacts (at least two to three years). Capacity to undertake and evaluate these projects must be built and supported through the other activities suggested below.

Action 7.1
Establish multi-component community-based tobacco control projects that are locally developed and delivered.
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Social marketing for indigenous people
Mainstream social marketing campaigns are effective in increasing awareness and understanding of the health effects of smoking among Indigenous people.
Research conducted by the NSW Cancer Institute in 2008 indicates that many mainstream advertisements are considered personally relevant by Indigenous smokers. However, there should be more representation of Indigenous people and relevant themes in campaigns where possible. This may include talent, language, situations and calls to action relevant to Indigenous people. Messages also need to challenge the acceptability of smoking and the inevitability of smoking-related diseases for Indigenous people.

Campaigns that more accurately reflect the life of an Indigenous smoker, in terms of the high prevalence of smoking, experience of smoking-related health effects and cross-generational smoking behaviour, are likely to be powerful in moving Indigenous smokers further along the continuum towards quitting.
Research in New South Wales and experience in Western Australia suggest that the optimum way forward involves a ‘twin track’ approach of using existing effective mainstream campaigns and adding complementary Indigenous-specific campaign elements. Experience has shown that radio offers a number of opportunities as an inexpensive and complementary medium that can be tailored to local and regional areas.

As with all social marketing, campaigns must be of high quality, based on research, sustained – that is, ongoing for several years rather than one-off efforts – and sufficiently well funded to allow appropriate TARP levels to demonstrate an impact.

Action 7.2
Enhance social marketing campaigns for Indigenous smokers, ensuring a ‘twin track’ approach of using existing effective mainstream campaigns complemented by Indigenous-specific campaign elements.

Train indigenous health workers
Indigenous health workers should be supported to lead tobacco control activities (and also to be non-smokers). Training is needed to improve knowledge about tobacco use and to build skills in service and program delivery, including:

• Providing brief interventions
• Developing, implementing and evaluating community-based tobacco control programs
• Collection and use of data and evaluating programs

Action 7.3
Provide training to Aboriginal and Torres Strait Islander health workers to improve skills in the provision of smoking cessation advice.

Train all staff working in indigenous health services
Training should include realistic and empowering strategies on how to discuss smoking cessation with patients, and how to develop programs that encourage change in social norms within communities around smoking. Training should be integrated in the multi-component community-based projects (Action 7.1 above).
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Action 7.4
Improve training in the provision of smoking cessation advice of other health professionals working in Aboriginal and Torres Strait Islander health services.

Building capacity of local health services
Indigenous health workers are already burdened with their daily work, and may have insufficient time and support to undertake tobacco control activities. Specialist workers have been successfully used in other areas, such as drug and alcohol therapy, sexual health and mental health.

Specialist Tobacco Control Workers are needed to assist local Indigenous health services to build their capacities to address tobacco use. The responsibilities of such workers will depend on local requirements but may include:

• Facilitate training and provide support to health service staff in tobacco control
• Support and advise health workers to lead in the development and delivery of community tobacco control programs
• Assist Indigenous organisations to develop and implement policies for smoke-free workplaces
• Advocate for the needs of Indigenous health services in the area of tobacco control (for example, around improved access to NRT)
• Provide support to multi-component community-based tobacco control projects (see Action 7.1)
• Assist Indigenous organisations to develop programs and policies that can support Indigenous health workers to quit smoking
• Collect smoking-related data at the local level
• Support communities and organisations to evaluate tobacco control programs

A clear structure is needed to support these Tobacco Control Workers. The BREATHE Project at the Aboriginal Health and Medical Research Council of NSW has a trial in place of Specialist Tobacco Control Workers in four Aboriginal Medical Services. This project could provide a model. A training package developed as part of the project could be enhanced (with further funding) to be used nationally with Specialist Tobacco Control Workers.

Action 7.5
Place specialist Tobacco Control Workers in Indigenous community health organisations to build capacity at the local health service level to develop and deliver tobacco control activities.

Increase employment of indigenous staff in NGOS
The work of NGOs in the area of Indigenous tobacco control could be enhanced by the employment of Indigenous workers. Where possible, at least two workers should be employed to maximise the provision of a supportive work environment for Indigenous people.

Action 7.6
Provide incentives to encourage NGOs to employ Indigenous workers.

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