In Australia, 50% of Indigenous people smoke which is double the rate of non-Indigenous Australians. The Northern Territory, in particular, has the highest rate of tobacco use in the country and tobacco consumption is the single biggest contributing risk factor for mortality amongst Indigenous Australians.

For several years the Menzies School of Health Research have been investigating the reasons behind this overwhelming disparity in tobacco consumption in Indigenous Australians and in 2007.established a ‘Tobacco Control Research Program’ to investigate this further.

A major part of the research agenda, led by Menzies researcher Dr Vanessa Johnston, was to investigate the reasons why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting.

Research methods included in-depth interviews with 25 Indigenous community members, 19 health professionals and other stakeholders. Observation of smoking behaviours and informal discussions with community members also provided additional data for analysis.

The results, Dr Johnston believes, indicates that there is a “complex interplay of historical, social, cultural and physiological factors” which influence the smoking behaviours of Indigenous adults in these communities.

“Although this has not always been the case, smoking today in some remote settings and the sharing of tobacco is strongly embedded within the social fabric of communities” Dr Johnston has discovered.

With 50% of all adults smoking, (in some communities the rate is over 70%), tobacco consumption is seen as normal behaviour into adulthood and there are many reinforcing social cues to smoke.

The role of smoking within the family is a key driver of starting to smoke, as results from interviews indicated that initiation of smoking was almost universally influenced by family smoking practices.

“Modelling of adult smoking behaviours was a key reason given by participants for their first smoking experience” says Johnston.

As one of the research participant’s stated:

“I had seen a lot of people smoking; well I copy from my mother and my grandmother and my grandfather.”

Johnston goes on to suggest that high rates of smoking are sustained because tobacco use, in particular, the sharing of cigarettes, reinforces family and social relationships.

In this context, smoking is not only an important social lubricator; it is also used as an aid to social cohesion.

“It is important to understand that sharing tobacco in this context may be used as a means to uphold social obligations and, to partake in reciprocal exchange as an expression of love, affection and relatedness” she continues.

On the other hand, non-participation can mean non-smokers feel isolated and marginalised in their communities. In some cases an individual’s choice not to smoke may lead to friction within relationships as highlighted by the following quote from a participant in the research:

 “My husband said to me ‘‘Why you not smoking? The other people, they are all smoking. You smoke,’’ he said to me. He was forcing me. ‘‘You help me,’’ I said ‘‘can I have just one and test the smoke?’’ And I smoke it.”

Sharing a smoke also provides a context for yarning (talking), sharing feelings and experiences and may present social opportunities not open to non-smokers.

The sharing of cigarettes, the meanings imbued by the practice and the ease with which such sharing is transacted all make quitting especially difficult as is noted here:

 ‘‘…There is always somebody with cigarette – friend to friend, family to family.’’

Interestingly, while most participants were influenced by family to initiate and continue to smoke, the health and well being of the family was a key driver of quit attempts.

Several themes emerged here - smokers were concerned with protecting the health of their young children from second hand smoke, they wanted to act as positive role models for their children, and were generally tired of the negative impact smoking was having on the family unit (e.g. the constant hassling for cigarettes, the associated cost, and the fighting and “crankiness” that occurred when the supply ran out).

An interesting finding was that even when health was identified as the motivation to quit, this was usually narrated through the lens of the family and not in relation to the consequences on the individual.

“Indigenous smokers in this study wanted to improve their health in order to see their children and grandchildren grow up and fulfil their familial responsibilities to them” notes Dr Johnston.

“The importance of protecting the health of children was the central theme throughout these results, suggesting that “focusing on preventing children’s exposure to second hand smoke may be useful strategy to influence quitting”,

This year the tobacco control research team is embarking on a new trial to test the effect of a family-centred tobacco control program about second-hand smoke on the respiratory health of Indigenous infants in the first year of life. The project is called ‘Healthy Starts.’ An exciting development is that the trial will be replicated among Maori communities in Auckland, New Zealand, to test its effect across different Indigenous populations.