A ustralia is considered to be a leader among developed nations in the area of tobacco control. Well coor- dinated and sustained tobacco control programmes are likely to have resulted in long term health gains, including a decrease in mortality rates from cardio- vascular disease, and subsequent in- creases in life expectancy. However, Aboriginal and Torres Strait Islander people—the indigenous people of Australia—continue to suffer high mortality and morbidity rates from con- ditions related to tobacco use. Indeed, tobacco is the main cause of preventable mortality among Aboriginal and Torres Strait Islander Australians. 1 How is it that a minority group within a wealthy nation can display such marked health status and tobacco use differences from others in that population? What has been done to attempt to redress this dis- parity? What are the needs and priorities for the future? In this commentary, we describe cultural, historical, and political factors leading to the high prevalence of smoking among Aboriginal and Torres Strait Islander people. We outline and discuss intervention efforts undertaken so far and consider their merits and weaknesses, paying particular attention to resource allocation issues. Finally, we consider priorities for future programme delivery that would be most likely to result in reduced tobacco use among this population. PREVALENCE OF TOBACCO USE As for other indigenous people world- wide, particularly those who have been colonised by other people (for example New Zealand Maori, 2 native Canadians, 3 and native Americans), the prevalence of tobacco use is higher among Australian Aboriginal and Torres Strait Islander people than for other Australians. In the National Aboriginal and Torres Strait Islander Survey 4 conducted in 1994, 54% of Aboriginal and Torres Strait Islander men and 46% of Aboriginal and Torres Strait Islander women were smokers, with very few Aboriginal and Torres Strait Islander people being ex- smokers. Studies have indicated that in some communities the prevalence of tobacco use is as high as 83% among men 5 and 73% among women. 6 By comparison, in 1998 25% of Australian men and 20% of Australian women were smokers. 7 Although some Aboriginal and Torres Strait Islander people chew tobacco or smoke traditional pipes, as for other Australians 8 most smoke tailor made or roll your own cigarettes and consume similar quantities to other Australians. 47 Uptake of smoking is often at an earlier age than for other Australians. 6 Patterns of tobacco use may differ from those for other Australians; many Aboriginal and Torres Strait Islander people share to- bacco and smoke sporadically according to availability of money for tobacco. MORTALITY RELATED TO TOBACCO USE The health status of Aboriginal and Torres Strait Islander people is markedly worse than that of other Australians. There is an abundance of information documenting the burden of morbidity and premature mortality experienced by Aboriginal and Torres Strait Islander Australians; in 1992–1994 they had a life expectancy that was 15–20 years less than that of other Australians (75.0 years for males born in 1994 and 80.9 years for females). 9 10 In a model used for calculating life expectancy for 15 year old Australians, regular tobacco use was likely to reduce life expectancy by 6.5 years in males and 5.1 years in females. 11 Arnold-Reed et al calculated the gain in life expectancy that would be expected in Aboriginal and Torres Strait Islander peoples if additional alcohol and tobacco related deaths were eliminated. 12 If to- bacco related deaths were eliminated, life expectancy for men would increase from 58.5 years to 61 years, and for women would increase from 65.3 years to 67 years. However, modeling of life expectancy is likely to provide conserva- tive estimates of potential increase in life expectancy because other factors such as maternal and childhood malnutrition, and exposure to campfire smoke and dust, may also exacerbate the effects of tobacco use. Aboriginal and Torres Strait Islander people experience 2–8 times the death rate of others in all age groups, 13 how- ever, the percentage of deaths attribut- able to tobacco use is likely to be similar to that in the mainstream population— about 15%. 14 15 Aboriginal and Torres Strait Islander people exhibit higher rates of tobacco related diseases such as cardiovascular diseases and pneumonia, cervical cancer, cataracts, and ear disease than other Australians. They are hospitalised at 2–3 times the rate of people in the general Australian population, with respiratory disease—much related to tobacco use— and injury being the most common causes of hospitalisation. 10 REASONS FOR THE HIGH PREVALENCE OF TOBACCO USE The high level of tobacco use and subse- quent harm among Aboriginal and Torres Strait Islander people may be related to a number of factors. Aboriginal people have long chewed the dry leaves of pituri (Duboisia hopwoo- dii) and native tobacco such as Nicotania gossei and N excelsior prior to contact with non-Aboriginal people. 16 Some Aborigi- nal people continue to use pituri and native tobaccos. Macassan fishermen and trepangers introduced tobacco into northern Australia approximately 400 years ago. 17 People in this region con- tinue to use Macassan style pipes and tobacco still plays a role in traditional ceremonies. Such traditional use of tobacco may reinforce its use today, although not all Aboriginal and Torres Strait Islander people used tobacco traditionally—for example Aboriginal people in southeastern Australia are unlikely to have had access to tobacco until contact with Europeans. In some Aboriginal and Torres Strait Islander communities traditional beliefs held by community members may influ- ence their tobacco use or their percep- tions of the benefits of quitting. A specific example is that in some tra- ditional Aboriginal and Torres Strait Islander societies people may believe that serious illnesses that are, according to the biomedical model, caused by tobacco are rather caused by sorcery, interpersonal conflict, or the breaking of taboos, which may mean that a cessation message is not seen as believable. How- ever, there is great cultural diversity in Aboriginal and Torres Strait Islander communities and not all will hold such beliefs. The process of colonisation of Aus- tralia meant that many Aboriginal and Torres Strait Islander people came into contact with tobacco through missionar- ies, miners, fishermen, anthropologists, and cattle station workers. Tobacco was highly valued by Aboriginal and Torres Strait Islander people 18 and Europeans often used it to manipulate them. 19 Until Aboriginal and Torres Strait Islanders ................................................................................... Aboriginal and Torres Strait Islander Australians and tobacco V L Briggs, K J Lindorff, R G Ivers ................................................................................... Suffering high mortality and morbidity rates from conditions related to tobacco use COMMENTARY ii5 www.tobaccocontrol.com on January 1, 2022 by guest. Protected by copyright. http://tobaccocontrol.bmj.com/ Tob Control: first published as 10.1136/tc.12.suppl_2.ii5 on 23 July 2003. Downloaded from