Cold turkey

TIS teams are funded to carry out population health promotion activities, not individual smoking cessation support. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports.

Evidence suggests that supported quit attempts (e.g. using nicotine replacement therapy (NRT), having group or individual counselling) are more successful than unaided attempts. However not everyone wants to use medicine such as NRT, or see a counsellor and many people who smoke quit unaided.

Unaided quitting is known as going ‘cold turkey’. People who smoke who want to quit this way should be advised to make a plan. Planning when they will quit and what they will do when cravings strike means they are more likely to succeed. The aim is to change the habits associated with smoking. This means thinking about things such as when and where someone smokes. Planning includes:

  • setting a quit date
  • throwing away smoking gear (e.g. cigarettes, ashtrays, lighters)
  • changing routines linked with smoking (e.g. instead of smoking in a work break go for a walk)
  • avoiding situations where they usually smoke
  • starting new activities (e.g. exercise) to replace smoking.

Using physical activity to enhance quit rates

TIS teams are funded to carry out population health promotion activities, not individual smoking cessation support. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports.

Other activities can support people to succeed in their attempts to quit. While nicotine addiction plays a big role in maintaining smoking behaviours, factors such as the social interactions that smoking supports, and psychological causes such as habit, also make it hard for people who smoke to quit.

Giving people new habits and ways of interacting to replace the gap left by not smoking may therefore be helpful. For example, if someone uses ‘going for a smoke’ with friends and family as a way of having a yarn or as an opportunity to debrief or blow off steam with co-workers, then it is important that they find other ways to engage in these important social interactions. So ‘come and have a smoke with me’ might become ‘come and have a cuppa’ or ‘come for a walk/bike ride/swim’.

Smoking and stress factsheet

There is some evidence that exercise can be an aid to smoking cessation. Recent evidence from Canada has shown that including a structured exercise program alongside nicotine replacement therapy (NRT) can increase quit rates and this is sustained over time. Exercise seems to reduce withdrawal and cravings for cigarettes. This may be because physical activity stimulates the reward centres in the brain in a similar way to smoking. The pleasurable ‘high’ that exercise delivers might also provide a distraction from the cravings and negative thoughts experienced during quitting.

Aerobic exercise (e.g. running, swimming, cycling) and some kinds of strength training (isometric) is especially helpful for reducing withdrawal symptoms and cigarette cravings. Effects can last as long as 50 minutes after the exercise session. As well as starting a regular exercise routine, someone trying to quit might use exercise as a distractor when an urge for a cigarette strikes. This might be as simple as going for a short walk. For more tips on coping with cravings see Box 1. To find out more about strategies for people who are quitting smoking to manage stress read the Key facts about smoking and stress factsheet.

In the longer term, exercise programs might help prevent relapse by boosting self-esteem, feelings of wellbeing and reinforcing a person’s self-image as a non-smoker and physically active individual.

Box 1: The four Ds guide to beat the craving…

Delay

Delay acting on the urge to smoke. Don’t open a pack or light a cigarette. After a few minutes, the urge to smoke will weaken.

Drink water

Sip some water slowly, holding it in the mouth a little longer to savour the taste.

Deep breaths

Take deep slow breaths in and out and repeat three times. Deep breathing will take the focus off the cravings.

Do something else

To take your mind off smoking, do something else:

  • listen to music
  • go for a walk or exercise
  • or talk to a friend.

Material adapted from:

Quitline

It is important that TIS teams work to improve Aboriginal and Torres Strait Islander people’s access to cessation support services such as Quitline. They can do this by raising awareness and understanding of these support services, addressing any misunderstandings, and promoting service use in their region. This might include referring people who smoke to Quitline, as well as providing education and information about the service.

There is some evidence that Aboriginal and Torres Strait Islander people may be reluctant to use the mainstream Quitline because of a perception that non-Indigenous counsellors would be unable to relate to them, or that they would talk down to them.

Since 2010, the Department of Health has provided funding to all Quitline services to enhance the capacity and knowledge of Quitline counsellors to enable them to deliver appropriate and culturally sensitive services to the Aboriginal and Torres Strait Islander population. Partnerships with Aboriginal and Torres Strait Islander communities have been built to promote and encourage use of Quitline services. This has included outreach work with counsellors, visiting services, and community events. Some services also employ dedicated Aboriginal and/or Torres Strait Islander counsellors.

Key facts about Quitline

Reports from Quitline providers indicate capacity, with most staff having undertaken training, and an increase in referrals to Quitline (both self-referrals and referrals by agencies) being seen across sites.

While uptake of services has clearly benefited from this approach, evidence for the effectiveness of Quitline for supporting cessation attempts by Aboriginal and Torres Strait Islander people is still limited. However, there is no reason to believe that culturally sensitive Quitlines would not be effective, as long as if people are able to access the service.

The NBPU TIS have produced a Key facts about Quitline factsheet that provides key information about the Quitline service for TIS workers including promotion of Quitline for cessation support, how Aboriginal and Torres Strait Islander Quitline counsellors can help community members and common questions about Quitline.

Counselling

TIS teams are funded to carry out population health promotion activities, not individual smoking cessation support. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports.

Behavioural counselling is well established as an effective support mechanism for individuals wishing to quit smoking. Counselling is effective when delivered either on a one-to-one, or in a group setting. There is a relationship between the intensity (length of session contact) and duration (number of sessions) of behavioural smoking cessation counselling and its effectiveness, but even low intensity counselling (3-10 minutes) improves quit rates.

Although the evidence is limited, intensive counselling (more than 10 minutes) has been shown to increase quit rates in some Aboriginal communities. For example, the

included intensive counselling as one component in addition to usual care (quit advice, pharmacotherapy, and patient-initiated follow up). Evidence shows that the program doubled quit rates from 6% to around 12%. This effect was found despite the intervention being implemented with less intensity than originally planned.

Brief intervention

Brief intervention (see Box 1) is accepted as an effective approach which increases quit rates in motivated individuals. This approach has been found to be most effective when combined with other interventions such as behavioural support, and nicotine replacement therapy (NRT). Although it is usually delivered in a one-to-one situation, increasing access to brief intervention training is an important and effective part of a population health promotion approach. This is because:

  • simple advice delivered in the right way can have a significant effect on smoking cessation
  • increasing the number of people in different organisations trained in brief interventions will increase our capacity to tackle smoking rates.

Specific barriers to the use of brief intervention with Aboriginal and Torres Strait Islander clients have been identified.

These include:

  • the high rate of smoking among Aboriginal and Torres Strait Islander Health Workers
  • the assumption by health workers that individuals will not be able to quit
  • cultural ways of being which value autonomy and seek to avoid confrontation.

Cultural beliefs are particularly important, as they mean that brief intervention is often seen to be inappropriately telling people how to behave.

Quitskills factsheet

Quitskills is a free, nationally recognised smoking cessation training program funded as part of the TIS program. The training provides participants with the confidence to support Aboriginal and Torres Strait Islander people to think about their smoking and support them with any changes they wish to make. You can find out more about the Quitskills program from the Key facts about Quitskills factsheet.

The Queensland Government developed a brief intervention training program, B.strong, for Aboriginal and Torres Strait Islander Health Workers and other health professionals to assist Aboriginal and Torres Strait Islander health clients and communities to address multiple health risks (smoking, physical activity and nutrition). The program included culturally sensitive, evidence-based training and resources. An evaluation of B.strong found that Aboriginal and Torres Strait Islander Queensland telephone counselling referrals for smoking cessation increased significantly during the program period.

More information on workforce training for brief intervention can be found here.

Because of the opportunistic nature of brief intervention, it is important that anyone who has contact with people who smoke from Aboriginal and Torres Strait Islander communities has culturally appropriate brief intervention training. In many organisations only health professionals, such as Aboriginal and Torres Strait Islander Health Workers, nurses, doctors, and dentists are trained to do brief interventions. However, because brief intervention is focused on motivation and education, not therapy, you do not need a health background to do this training. They are also opportunistic, meaning that they do not need to take place in a medical setting. This means anyone can do brief intervention training, including:

  • staff from health organisations, who are the first point of contact for clients (e.g. receptionists and drivers)
  • staff from non-health organisations that have regular contact with Aboriginal and Torres Strait Islander clients
  • smoke-free ambassadors or other volunteers who work on community events/outreach activities.

Box 1: What is a brief intervention?

Brief intervention makes the most of any opportunity to raise awareness, share knowledge and get someone to think about making changes to improve their health and behaviours. Brief intervention uses counselling skills such as motivational interviewing and goal setting. An understanding of the stages of behaviour change is also important. Brief intervention takes as little as 3 minutes and is usually carried out in a one-to-one situation. The 5As for smoking cessation for health professionals is an international smoking cessation framework used in brief intervention that has been shown to be very effective in encouraging and supporting smoking cessation. More information about the 5As can be found in this podcast developed for the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people featuring Professor David Thomas.

Pharmacology

Regional Grant funding does not cover TIS teams to offer nicotine replacement therapy (NRT) or other stop smoking medication (SSM) to people who smoke. This is because TIS teams are funded to carry out population health promotion activities, not individual smoking cessation support. However, it is important that TIS workers have up-to-date knowledge of the individual level cessation supports such as NRT and SSM, as these can inform population health promotion activities (e.g. community knowledge building).

A number of studies have examined the extent to which NRT is an effective smoking cessation treatment for Aboriginal and Torres Strait Islander populations. Overall NRT is effective, particularly if free/subsidised, and especially if accompanied by good follow-up support services. Evidence about the effectiveness of other SSM such as Varenicline (Champix) and bupropion (Zyban) in Aboriginal and Torres Strait Islander populations is limited. An article from the Talking about the Smokes (TATS) survey found that Aboriginal and Torres Strait Islander people are less likely to use NRT or SSM as part of a quit attempt (37%) than non-Indigenous people who smoke (58.5%). However, just under three quarters of those surveyed believed NRT and SSM did help people who smoke to quit. Cost is probably the main barrier to using pharmacological aids. Nicotine patches – available to Aboriginal and Torres Strait Islander patients at a subsidised cost on an authority script through the Pharmaceutical Benefits Scheme (PBS) – were the most common pharmacological aids used by Aboriginal and Torres Strait Islander people who smoke and recent ex-smokers (24%). Varenicline was the next most commonly used pharmaceutical at 11% and nicotine gum at 10%.

Observational research in remote Northern Territory communities, found that following recommended treatment for using NRT (compliance) can be limited by factors such as:

  • difficulties maintaining NRT supplies in remote areas
  • individuals running out of patches because they share with other family members
  • cost, particularly for forms not on the Pharmaceutical Benefits Scheme (PBS).

However, observation of the successful delivery of NRT in one community by a public health nurse showed how compliance improves when regular support and counselling is provided: NRT was supplied in one week blocks with face-to-face follow-up every week at the client’s home. There is also evidence from the

that combining NRT with intensive counselling and support is effective even in remote settings.

This suggests that focusing on increasing compliance is likely to improve quit attempts. This can be done through:

  • greater discussion around NRT options (e.g. gum, patches or combined therapy)
  • including patients in the decision process
  • providing appropriate regular support.

    NRT factsheet

Other activities to increase the use of NRT in helping Aboriginal and Torres Strait Islander people who smoke to quit are:

  • providing better information about NRT to the community
  • including access to NRT as part of a broader tobacco control program.

Another program which demonstrates the effectiveness of a comprehensive service for supporting quit attempts is the No More Boondah smoking cessation program based in ACT. The program combines weekly support groups, access to NRT (through a GP), phone follow-up, and home and workplace outreach.

You can find further information about nicotine replacement therapy in the video and factsheet produced by NBPU TIS which can be downloaded here.

Further reading

Social media and social networking

Social media and social networking tools such as Facebook, Instagram, TikTok, YouTube, Snapchat and Twitter are increasingly being used to help tackle smoking, particularly with young adults. One of the advantages of these platforms is that they are accessible, low cost and familiar to young people. About 20.5 million Australians are active users of social media – around 80% of the total population. Research by the McNair Ingenuity Research Institute in 2014 found that Facebook is a popular means of communication among Aboriginal and Torres Strait Islander people.

The use of Facebook and Twitter as a way of communicating is a popular approach for many healthcare services. However the value of these tools seems to lie more in their networking functions. Social media is interactive and user-driven, meaning it has the potential to provide real-time peer to peer support and discussion around tobacco use.

There is currently a lack of evidence of the effectiveness of using social media in tobacco control. Studies that do exist tend to be descriptive, with a focus on the acceptability of the medium to support quitting, or an analysis of posts. A study on using Facebook to reduce smoking among Aboriginal and Torres Strait Islander people found that there was potential for health services to incorporate a strategy of using paid local social media ‘champions’ or ‘ambassadors’ to disseminate tobacco control messages on Facebook through community networks. It also found that:

  • posts were more likely to be shared if they:
    • were child-focused
    • featured Aboriginal and Torres Strait Islander content
    • were perceived as practical, relevant and credible, with a direct and unambiguous message.
  • posts were less likely to be shared if they:
    • included disgusting imagery about health impacts
    • were focused on the environment
    • were ambiguous or sarcastic.

The NBPU TIS have produced a Key facts about social media factsheet and infographic that provide key information for TIS workers about using social media to communicate messages about smoking.

Social media factsheet

Social media infographic

 

Claudine Thornton’s social media training

A bespoke online social media training course has been developed for the TIS workforce by Claudine Thornton Creative. You will learn about marketing terminology and consumer behaviour tactics. Understanding how marketers use emotion over logic in promoting cigarettes, means you can use the same tactics to persuade people to be smoke-free. The course focuses on how to use emotional availability to reverse engineer tobacco marketing. The course lasts around one and a half hours and comprises seven modules each split into 5-10 minute segments.So you can complete it in one go, or in short pieces. The course is free to access, simply open this link and then click the ‘Enroll for free’ button.

Menzies School of Health Research has produced a tips and tricks resource for people working in health promotion and tobacco control, Social media in health promotion and tobacco control: tips and tricks. An accompanying PowerPoint presentation, Can Facebook help Aboriginal and Torres Strait Islander people to quit smoking? is also available.

Monitoring and reporting social media activities presentation

Monitoring and reporting on social media activities

This presentation from A/Prof Penney Upton discusses the monitoring and reporting of social media activities, including:

  • reach
  • engagement
  • impact.

Please note: The presentation will start playing automatically when opened.

Mass media and social marketing

Mass media and social marketing campaigns aim to reduce the number of people who smoke by changing attitudes, beliefs and intentions surrounding tobacco use. Mass media campaigns take a traditional marketing approach to this aim, treating the desire to be smoke-free as a product to be sold. In contrast, social marketing uses knowledge of specific community barriers to develop more targeted marketing approaches.

Both approaches use education about the negative consequences of smoking and the benefits of not smoking for two purposes:

  • to prevent the uptake of smoking (particularly in young people)
  • to promote quit attempts in people who currently smoke.

It is thought these campaigns help to prevent smoking by changing people’s expectations toward smoking, so that tobacco use is no longer accepted as the ‘usual, cool or necessary thing to do.’

A 2021 publication from the Mayi Kuwayu study showed that education provided by the TIS program has changed awareness and understanding of the impact of smoking on long term health in Aboriginal and Torres Strait Islander adults. We know that negative attitudes towards smoking are an important precursor to smoking behaviour change. Anti-smoking attitudes are more likely to lead to quit attempts, and to successful long term smoke free living.

There is evidence that both mass media and social marketing campaigns can help prevent smoking from starting, encourage people to stop smoking, and prevent relapse among recent quitters by reminding them about why they chose to stop smoking. However one of the biggest effects is in relation to promoting access to cessation support services such as Quitline, counselling and other health professionals. Developing capacity to support people who are ready to quit – by taking the systems approach described under Planning, is therefore essential if programs are to be sustainable.

A campaign’s impact is influenced by:

  • repetition – the more often the messages are heard, the more likely they are to sink in
  • reach – how far the messages are spread, how large the audience is
  • intensity – how regularly the messages are heard
  • how long the campaign is – it needs to be long enough for all target audiences to have heard the message but not so long that they get sick of it and tune out.

Don’t Make Smokes Your Story campaign ad

The relevance of the message has been found to be important for audience engagement. The context, characters and role models used in advertising or community activities must seem believable, if people who smoke are to connect to them. When a campaign does not relate to how people see themselves, they find it hard to become interested in the content. While there is some evidence that mass media campaigns do influence attitudes and beliefs of Aboriginal people and Torres Strait Islanders in regard to smoking, more specific local messages tailored for Aboriginal and Torres Strait Islander people seem to be most effective. Evidence from the Talking About The Smokes project also supports the importance of using targeted advertising.

The Australian Government’s Don’t Make Smokes Your Story campaign is a good example of how advertising and community-based activities can work together to encourage behaviour change among Aboriginal and Torres Strait Islander people who smoke. You can adapt and use these materials and resources for your own activities.

Smoke-free

Reducing second-hand and third-hand smoke

Reducing second-hand and third-hand smoke is an important aim. This is because second-hand and third-hand smoke can be very harmful. The evidence also shows that if smoking is seen as ‘normal’ at a community level, young people are more likely to start smoking, and people who currently smoke will find it harder to quit. Increasing the extent to which a community is smoke-free is associated with less smoking and more success in quitting. A 2021 publication from the Mayi Kuwayu study showed that areas of Australia where the TIS program is present, compared to non-TIS areas, have a significantly lower prevalence of smoking inside households.

Relevant activities include the following:

Developing smoke-free policies in the workplace

To be successful, smoke-free policies need community participation – not just consultation – in their development. Policies that have local ownership and commitment are more likely to be followed. There is also evidence that introducing smoke-free policies in the workplace can lead to increased support for smoke-free spaces in other areas such as smoke-free homes and cars. Successful smoke-free workplace policies also result in more workers wanting to quit.

Combining locally owned smoke-free policies with access to quit support services increases the success of these policies. Working in an environment with a smoke free policy can also encourage individuals to quit.

Here are some quick tips on setting up a smoke-free environment: How to set up a smoke free environment.

The Aboriginal Health and Medical Research Council (AH&MRC) of New South Wales provide a good set of resources to help you support workplaces to set up smoke-free policies.

provides: advice on how to begin the process; templates for worker consultation; and templates to assess how much smoking happens at work.

Supporting smoke-free homes and cars

Second-hand and third-hand smoke is a health risk factor, particularly for children. Children are at greater risk for a number of reasons, including their size, faster breathing rates and less developed respiratory and immune systems. Second-hand smoke is associated with a number of childhood illnesses including:

  • asthma
  • croup
  • bronchitis
  • bronchiolitis
  • pneumonia
  • ear, nose and throat infections.

Second-hand smoke is also believed to contribute to the risk of sudden infant death syndrome (SIDS).

Less well known, but probably just as harmful is third-hand smoke. Third-hand smoke is the tobacco smoke toxins from second-hand smoke that get into people who smoke’s hair and clothes and build up on surfaces and dust in areas where people smoke. Evidence shows that these toxins stay in homes and cars for a long time after the cigarette has been extinguished, even several months later. They may even become more toxic over time.

Bullinah Aboriginal Health Service’s Solid Mob ‘Our home is a smoke free zone’ campaign

Third-hand smoke is an emerging area of research and we don’t yet understand all the health hazards. However, children (especially infants), are more vulnerable to third-hand smoke toxins. This is because infants crawl over contaminated floors and mouth contaminated surfaces like furniture and toys. We also know that infants consume up to a quarter of a gram of dust every day. That’s twice as much as adults.

There is good evidence that having a smoke-free home and car improves children’s health. There is also some evidence that keeping the home smoke-free helps to prevent uptake of smoking by young people. There are therefore many good reasons to support people to have smoke-free homes and cars.

2018 review found that intensive counselling methods or motivational interviewing with parents to be most effective for reducing children’s tobacco smoke exposure in the home. There is some indication that school-based education, intensive home visits, brief education provided to parents in clinics (including scheduled children’s health checks) and culturally sensitive health promotion brochures may also help reduce second-hand smoke in the home and car.

Menzies School of Health Research has developed Healthy starts: reducing the health effects of smoking around Indigenous babies and childrena resource to support health providers when discussing second-hand tobacco smoke with families, and to encourage families to have smoke-free homes.

Running smoke-free events

Griffith AMS hosting a smoke-free community event

Any opportunity to reduce second-hand smoke is a good investment because there is no safe level of exposure to second-hand smoke, and smoke-free events both denormalise smoking and encourage people to think about quitting. The Talking About The Smokes (TATS) study found that support for smoke-free festivals and events is strong in Aboriginal and Torres Strait Islander communities, particularly among those who don’t smoke:

  • for people who have never smoked, support was 71%
  • for ex-smokers 65%
  • for people who do not smoke daily 70%
  • half of all people who smoke daily were in favour of smoke-free events (51%).

Smoke-free pledges

Pledging to be smoke-free demonstrates an active commitment and motivation to change. Evidence shows that when someone makes a public declaration (pledge) they are more likely to follow through with that promise, both for themselves, but also because of what others might think of them if they don’t maintain their promise. We also know that people are more likely to stick with a commitment that has real value, purpose and meaning to them.

Smoke-free pledges are a good population health promotion tool because:

  • group pledges (e.g. family, organisation or community) seem to be more effective than individual ones – this is probably because of the social support that a group pledge provides
  • pledges can be linked to any environment – e.g. smoke-free workplaces, smoke-free homes
  • pledges can be used as a part of different activities – e.g. at community events and workplace education sessions
  • as well as supporting behaviour change, pledges can be used to monitor an activity’s reach and impact.

The Wellington Aboriginal Corporation Health Service Quit B Fit Team encouraging people to take a pledge to not smoke in their homes, cars and workplaces

You can find further information on smoke-free environments in the video and factsheet produced by NBPU TIS which can be downloaded here.

Choosing evidence-based activities

Once you have decided what you want to accomplish through your program, you will need to choose activities that will help you to achieve these aims. It is important that Tackling Indigenous Smoking (TIS) activities are effective for achieving the proposed outcomes of the TIS program (e.g. increasing awareness of the benefits of not smoking, more smoke-free environments, increased quit attempts, reduced uptake of smoking). The best way of ensuring that an activity is effective is to use ones which have been tried and tested, so we have evidence that they work. It is also important that you choose the right activities for your local population needs and your local community context. Your role is to use your understanding of the communities in your region, your professional experience and expertise, along with your knowledge of the evidence to put together a suitable set of activities.

Population health promotion

The TIS program uses population health promotion activities to reduce the prevalence of smoking in Aboriginal and Torres Strait Islander communities. TIS is a tobacco control program, not a smoking cessation program. It aims to reduce smoking prevalence by preventing the uptake of smoking, as well as encouraging people who smoke to quit. Regional Tobacco Control Grant (RTCG) teams are funded to provide community outreach, rather than clinical individual level action to improve the health and wellbeing of all Aboriginal and Torres Strait Islander people.

Click on the image on the left to read about the principles of population health promotion that should underpin all of your TIS activities.

 

What do we mean by evidence?

Evidence is the information or knowledge about ‘what works’ which can help you decide which activities you will use. Evidence comes from many different sources including published research, and many professionals value this kind of evidence the most. However published research about TIS activities is not always available. Local evidence that an activity works also has an important role to play in the development of TIS activities.

Figure 1: Using the evidence to develop locally relevant services

This is one reason why the careful monitoring and evaluation of local activities is an essential part of the TIS program. Collecting accurate and thorough local data will help you to see what works best and this information can then be used to improve your activities. You can also share this with other TIS-funded organisations and contribute to the evidence on what works for TIS.

Sometimes collecting data can be challenging – the number of participants in a program may be small, or it may be that it can take a long time to see changes in smoking behaviour in the wider community. The NBPU TIS can support teams to address these and other challenges in order to develop the evidence base for TIS.

It is important to remember that the evidence does not provide a set of fixed solutions (it is not a ‘recipe book’). It is one element in an ongoing process. Your decision making will draw on your professional expertise about TIS and the local community with the evolving local and research evidence to develop a locally relevant service (Figure 1).

 

What is the current best evidence to support the reduction of tobacco use?

Quitting smoking is the best way to reduce tobacco-related harm. Individuals may make several quit attempts before successfully stopping smoking for good. This is why health promotion activities and community development to support quitting are so important; it’s about continually reminding people of the importance of quitting and informing them about where to get help. It is important that as well as providing education about tobacco harms, organisations providing health promotion activities are able to refer people who want to quit to smoking cessation support services. Being part of a wider health service system or network is therefore essential for TIS teams.

Evidence from a large-scale cohort study recently showed that Aboriginal and Torres Strait Islander adults living in TIS-funded areas were more likely to be smoke free at home, to smoke less tobacco and show lower rates of nicotine dependency compared to Aboriginal and Torres Strait Islander adults who lived in non-TIS areas.