“The research is a positive news story in Indigenous health, and more should be done to understand what is working to reduce Indigenous smoking”
Professor Tom Calma, lead advocate for Indigenous tobacco control and Chancellor of the University of Canberra
Read over 118 NACCHO Aboriginal Health and Smoking published over the past 5 years
A paper led by ANU researcher Associate Professor Ray Lovett published in the journal Public Health Research & Practice today found a substantial drop in smoking among Aboriginal and Torres Strait Islander people over the last ten years.
The research highlights the positive downward trends in daily smoking prevalence for young Indigenous people and Indigenous people living in urban areas.
The majority of Aboriginal and Torres Strait Islander adults (around six in ten) do not smoke daily.
According to the study, the proportion of Indigenous people smoking daily dropped by 9%, from 50% in 2004 to 41% in 2014.
Lovett explains, ‘As a result, there are 35,000 fewer daily smokers today than there would have been if things had stayed the same since 2004. This will lead to thousands of lives saved’.
‘The way we communicate statistics matters. In our work we focus on the progress made within the Aboriginal and Torres Strait Islander population, and we find that substantial progress has been achieved.
In contrast, when reports focus on the gap in smoking prevalence compared to the total Australian population, this can have negative consequences and can actually contribute to widening the gap’, said Lovett.
The team used data from national surveys conducted by the Australian Bureau of Statistics to assess trends in Indigenous smoking over time.
Dr Lovett and his research team are now working with two Aboriginal organisations, Central Australian Aboriginal Congress and Institute for Urban Indigenous Health, to better understand how their work contributes to the decline in smoking rates.
The full article can be found here: http://www.phrp.com.au/?p=37127
Discussion
The prevalence of daily smoking among Aboriginal and Torres Strait Islander adults in Australia has decreased by 8.6 percentage points (95% CI 5.5, 11.8), from 50.0% in 2004–05 to 41.4% in 2014–15.
This corresponds to an estimated 35 000 fewer Aboriginal and Torres Strait Islander adult daily smokers in 2014–15, compared with if the smoking prevalence had remained stable since 2004–05. Our findings indicate that thousands of premature deaths in Aboriginal and Torres Strait Islander people have been prevented by the reduction in daily smoking prevalence over the past decade.
Accurately determining the number of deaths averted requires additional data, such as cause-specific mortality. Declines in daily smoking among Aboriginal and Torres Strait Islander people were observed among both males and females, and were most evident among those aged 18–44 years, and those living in urban/regional areas.
The absolute decrease in smoking prevalence observed in the Aboriginal and Torres Strait Islander population is comparable with the decrease of 6.8 percentage points (95% CI 5.6, 7.9) in the total Australian population over the same period, although the base smoking prevalence was substantially lower in the total Australian population (21.3% in 2004–05). These results demonstrate that considerable progress has been made in the Aboriginal and Torres Strait Islander population in the past decade, matching in absolute terms the extent of progress made in the total Australian population.
Given the similar absolute decrease in smoking prevalence in the Aboriginal and Torres Strait Islander and total Australian population, the gap in smoking prevalence has remained relatively stable. This may appear inconsistent with the Australian Institute for Health and Welfare’s midterm report for the National Tobacco Strategy 2012–20185, which reported that the gap in smoking between Aboriginal and Torres Strait Islander people and non-Indigenous Australians had increased between 2008 and 2015.
The discrepancy arises from different methods used to report trends in smoking inequalities.9-11 Our analysis emphasises change in the absolute prevalence of smoking within the population (50.0% – 41.4% = 8.6% absolute prevalence decrease), whereas the midpoint report emphasises smoking prevalence in the Aboriginal and Torres Strait Islander population relative to the non-Indigenous population.5
In relative terms, the ratio of Aboriginal and Torres Strait Islander to total Australian smoking prevalence increased from 2.4 (50.0%:21.3%) in 2004–05 to 2.9 (41.4%:14.5%) in 2014–15. This demonstrates that reporting change in absolute versus relative terms can lead to fundamentally different conclusions, which could affect support for programs and policies.9-12
Focusing on relative differences in isolation can obscure progress at the population level; that is, the absolute number of Aboriginal and Torres Strait Islander adults quitting or not taking up smoking.
Further, research from other populations demonstrates that communicating information about health inequity using a progress frame (as used in this paper) rather than a disparity frame (i.e. focusing on the persisting gap) is associated with more positive emotional responses and increased interest in engaging in health-promoting behaviours.14 Therefore, we consider it ethical to report absolute progress in smoking prevalence.
The ambitious target to halve Aboriginal and Torres Strait Islander adult daily smoking prevalence to 23.9% by 20186 will not be achieved if current trends continue. However, this target would be reached within the next two decades if smoking prevalence continues to decrease at the current rate. If the success in smoking reduction observed within the younger age groups and those living in urban/regional areas is echoed in older age groups and in remote areas, this target may be reached earlier.
We observed significant reductions (about 10%) in daily smoking prevalence among the youngest age groups (18–24, 25–34 and 35–44 years). Data from the 2004–05 NATSIHS indicates that two-thirds of current and past Aboriginal and Torres Strait Islander smokers had begun smoking by age 1817; therefore, our findings of reduced smoking prevalence among younger adults is promising.
The Aboriginal and Torres Strait Islander population has a younger age profile than the total population, and therefore the potential population-level benefit of reducing smoking among younger adults is important.18
We observed reductions in daily smoking prevalence among male and female Aboriginal and Torres Strait Islander adults living in urban/regional areas. Given that the majority of Aboriginal and Torres Strait Islander people live in urban/regional settings, this is another encouraging finding at the population level.
We did not detect a significant change between 2004–05 and 2014–15 in daily smoking prevalence among Aboriginal and Torres Strait Islander adults living in remote areas. The observed stability of smoking prevalence in remote areas from 2004 to 2015 is consistent with trends from 1994 to 2004.7 Despite being the largest available datasets, the number of survey participants in remote areas was relatively small, and is likely to be insufficient to detect changes in prevalence.
Given the enduring high smoking prevalence among older age groups and in remote settings, improved intensive effort will be required to change the normalisation of tobacco use and correct potential misperceptions of tobacco use, particularly as older people may have had longer and more intense exposure to tobacco marketing.19
This includes continued and concerted effort from targeted Aboriginal and Torres Strait Islander tobacco control programs, in addition to national strategies.4,20
The prevalence of smoking is reduced by increased numbers of people quitting and not taking up smoking. Since 2008, there has been a concerted effort in public health strategies, policies and programs to reduce tobacco smoking in Aboriginal and Torres Strait Islander people.
Australia’s approach to tobacco control is comprehensive, and it is difficult to attribute changes to one program; however, continuing support for both whole-of-population and targeted strategies is required.
For example, recent evidence indicates that the introduction of graphic warning labels on cigarette packages led to increased understanding of and concern about the harms associated with smoking among Aboriginal and Torres Strait Islander people19,21, and research has demonstrated that smokers’ knowledge of the effects of second-hand smoke is associated with desire and attempts to quit.22 Our findings may indicate that programs and policies have been particularly effective at reducing smoking among young people and those living in urban/regional areas. It is more difficult to assess the potential effectiveness of programs and policies in remote settings; finer regional estimates are required to assess policy and program impacts in this setting.23
Strengths and weaknesses
This paper analyses multiple cross-sectional data, which are the most comprehensive data available on Aboriginal and Torres Strait Islander smoking status. Limitations of our approach include that comparability between survey estimates may be affected by differences in scope, sample design, coverage, and potential changes in the age structure of the population over time. The use of weighting generates estimates that are representative of the in-scope population, which were similarly defined across the four surveys. However, we note that the 2004–05 and 2008 surveys represent a somewhat smaller percentage (82–90%) of the Aboriginal and Torres Strait Islander population compared with the other surveys (95%); this may result from issues related to survey scope.17
We have restricted our analysis to current daily smoking – rather than including weekly or less frequent smoking – to enable consistent measurement across surveys, and to enable direct comparison with national tobacco targets.5,6 It is important to note that our analysis focused on cigarette smoking. Recent ABS surveys provide data on the use of other tobacco products (e.g. chewing tobacco); data on e-cigarette use are not yet available.
Although we include a comparison with daily smoking prevalence in the total Australian population as a benchmark, this article focuses on variation in daily current smoking trends within the Aboriginal and Torres Strait Islander population. We have presented comparable estimates for the total Australian population, rather than the non-Indigenous Australian population, because of the data that were available, and we may therefore underestimate the gap in prevalence between the Aboriginal and Torres Strait Islander and non-Indigenous populations. However, this underestimation is likely to be very small; for example, in 2014, the difference between daily adult smoking prevalence in the non-Indigenous population (14.2%; 95% CI 13.4, 15.0)3 versus the total Australian population (14.5%; 95% CI 13.6, 15.4) was marginal.
Conclusions
Applying a progress frame rather than a disparity frame and reporting absolute changes in smoking prevalence provides clear evidence of the substantial and significant declines in daily smoking prevalence among Aboriginal and Torres Strait Islander adults, which will result in considerable health gain. Particular success has occurred among younger adults and those living in urban/regional areas.
Despite this progress, the smoking prevalence in the Aboriginal and Torres Strait Islander population remains high, with an estimated 165 000 current adult daily smokers. It will be critical to learn from the success among younger adults and those in urban areas to effect change among older age groups and those in remote areas. Continuation and enhancement of a suite of tobacco control efforts are required.