Smoking behaviours in a remote Australian Indigenous community: The influence of family and other factors☆
Introduction
Currently, tobacco use causes 1 in 10 deaths among adults worldwide or more than 5 million people a year, making it the leading preventable cause of death globally (Mathers & Loncar, 2006). Indigenous populations are consistently over-represented in smoking prevalence and associated morbidity and mortality statistics in developed countries throughout the world, including Canada, New Zealand and the U.S. (Anand et al., 2001, Bramley et al., 2005). In this regard, Australia is no different. Despite the fact that Australian tobacco control efforts have made significant inroads in reducing mainstream smoking rates over recent decades (Chapman & Wakefield, 2001), smoking rates among Indigenous people have, thus far, been resistant to such campaigns.
National statistics indicate that in 2004–2005, 50% of Indigenous adults were regular smokers – twice the rate of non-Indigenous adults (ABS, 2006). Local reports indicate smoking rates are in excess of 70% in some remote Northern Territory communities (Burgess, 2007). Notably, there has been no significant change in national Indigenous smoking rates since earlier surveys in 1994 and 2002 (ABS, 2004, Cunningham, 1997). As a consequence, 12% of the total disease burden among Indigenous Australians is attributable to tobacco use (Vos, Barker, Stanley, & Lopez, 2007). Tobacco use is the single most important risk factor for excess mortality and morbidity in Indigenous Australians; responsible for one-fifth of Indigenous deaths in 2003 and 17% of the ‘health gap’ between Indigenous and non-Indigenous Australians (Vos et al., 2007).
Despite the high prevalence of smoking among Indigenous Australians and the disproportionate health costs, relatively little attention has been given to research which focuses on this group. The little research that has been done has for the most part consisted of epidemiological studies of the incidence and prevalence of smoking and the links between smoking and disease (Ivers, 2001). More recent work has examined the social determinants of smoking and found that the most disadvantaged Indigenous people are less likely to be non-smokers, ex-smokers or never-smokers than more socially advantaged Indigenous people (Thomas, Briggs, Anderson, & Cunningham, 2008). This new information is valuable. However, the data were drawn from a large questionnaire and do not allow for a more in-depth exploration of the social context in which Indigenous people smoke or of Indigenous meanings and perceptions of smoking. Far less research, both in Australia and internationally, has qualitatively investigated these issues among Indigenous adults.
The importance of social context for the uptake and maintenance of smoking is increasingly acknowledged (Poland et al., 2006), especially among disadvantaged groups, where factors associated with low socioeconomic status (e.g. high unemployment, poor education, stress etc.) are implicated in high smoking and low quit rates (Baker et al., 2006, Baumann et al., 2007, Harwood et al., 2007, Haustein, 2006). Indeed, the only published qualitative research study of smoking among Australian Indigenous adults provides support for the significant impact of social and economic stressors, in smoking maintenance among pregnant women (Wood, France, Hunt, Eades, & Slack-Smith, 2008). Intersecting with the social is the cultural context in which smoking occurs. While tobacco is a global phenomenon, used across many different and varied ethnic groups, it is “culture [that] shapes the specific methods and patterns of its use” (Unger et al., 2003, p.S101). The reasons people use tobacco, the meanings of tobacco use, and the implications of not smoking are all determined to a significant degree by cultural context (Unger et al., 2003, p.S101). Given this, it is imperative to more fully understand the context in which Indigenous people start to smoke (or conversely never initiate the behaviour), the reasons why they persist in smoking and the obstacles and drivers of quitting. It is only when we understand these factors can policy and programs on tobacco control start to make some headway in reducing the alarmingly high rates of smoking among this population.
Section snippets
Aims
The study aimed to investigate among Indigenous adults:
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The reasons why and in what circumstances they started smoking,
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The reasons why and in what circumstances they continued to smoke,
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The obstacles and drivers of quitting smoking, and
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The contextual experiences of those who had never smoked.
Methods
Semi-structured interviews with Indigenous community members and health staff were used to investigate the views and experiences of smoking in two selected remote Indigenous communities. Observation of smoking behaviours in one Indigenous community and informal discussions with community members also provided additional data for analysis. A reference group, which included Indigenous representatives, provided input into the research process. This included guidance on questions to be included in
Study site
This study was conducted in the Northern Territory, the jurisdiction with the largest proportion of Indigenous people in Australia (around 30%) and where Indigenous smoking rates are highest in Australia (ABS, 2006). In the Northern Territory, the majority of Indigenous people live on Indigenous-owned land in discrete and often remote communities outside of major cities (ABS, 2007), which are often characterised by high comparative levels of socioeconomic disadvantage and underserved by both
Results
Data were collected between August and December 2007. Unless otherwise specified, ‘participant’ refers to the views of community members [CM]. Community members ranged in age from 23 to 67 years. There were 12 males and 13 females. Two had never smoked, 15 currently used tobacco (one chewed tobacco), 6 were ex-smokers and 2 were in the early stages of a quit attempt. Seven of the current smokers indicated that they contemplated quitting smoking. Of the 13 health workers [HW] interviewed, 4 were
Discussion
This study used qualitative methods to explore the reasons why Indigenous people in remote communities start to smoke (or not smoke), continue to smoke and quit. By more fully understanding these processes, we are better placed to design effective anti-tobacco interventions for this population, which has the highest smoking rate in Australia. There are some limitations to the study. Firstly, we were not able to recruit a significant number of people who had ‘never smoked’ and thus, the
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This research was supported by a grant from the Cooperative Research Centre for Aboriginal Health (No. CD 216). We would like to gratefully acknowledge the assistance of Sandy Djabibba, Laurie Magaldagi, Jill McDonald, HPaul Burgess, and Pamela Hepburn for their assistance in the fieldwork for this study.