Tobacco use has a number of health impacts, including increasing the risk of chronic disease, such as cardiovascular disease, many forms of cancer, and lung diseases, as well as a variety of other health conditions . Tobacco use is also a risk factor for complications during pregnancy and is associated with preterm birth, low birth weight, and perinatal death. Environmental tobacco smoke (passive smoking) is of concern to health, with children particularly susceptible to resultant problems that include exacerbation of middle ear infections, asthma, and increased risk of SIDS.
The 2014-15 National Aboriginal and Torres Strait Islander Social Survey (NATSISS) is currently the most reliable source of information on the prevalence of tobacco smoking among Aboriginal and Torres Strait Islander people. While the more recent report, the National Drug Strategy Household Survey 2016: detailed findings (NDSHS) has data from 2016, there are issues with the sample size of Aboriginal and Torres Strait Islander people, as well as some other limitations. Because of this, comparisons against non-Indigenous people must be interpreted with caution . The 2014-15 NATSISS also has more comprehensive data in terms of remoteness, sex and age.
The 2014-15 NATSISS found that 39% of Aboriginal and Torres Strait Islander people aged 15 years and over reported that they were current daily smokers . This represents a significant reduction from levels reported in the 2008 NATSISS (45%) and 2002 (49%). Findings from the NDSHS, which reported on Aboriginal and Torres Strait Islander people aged 14 years and over, also showed a significant decrease in smoking levels, but with smaller numbers of Aboriginal and Torres Strait Islander people, declining from 35% in 2010, to 32% in 2013 and 27% in 2016 .
A report which looked at long-term smoking trends among Aboriginal and Torres Strait Islander people has found that there have been some significant decline in smoking rates over the 20 year period 1994 to 2014-15 . In particular, smoking prevalence has decreased in those aged 18 years and over, and also in smoking initiation for the 15-17 years age-group. While the year-to-year declines in smoking rates reported in the major health surveys don’t always appear to be significant, this report shows that there are encouraging trends in the younger age cohorts which will results in improved health outcomes over time.
In 2014-2015, the proportion of Aboriginal and Torres Strait Islander males who were current daily smokers (42%) was higher than the proportion of Aboriginal and Torres Strait Islander females (36%) . Aboriginal and Torres Strait Islander males had the highest proportion of current daily smokers across all age-groups, most notably in the 45-54 years age-group (51% compared with 41% of females). For Aboriginal and Torres Strait Islander people, the age-group with the highest proportion of current daily smokers was 35-44 years (47%). After age-adjustment, Aboriginal and Torres Strait Islander people were 2.8 times more likely to smoke than non-Indigenous people (39% compared with 14% respectively).
In 2014-2015, Aboriginal and Torres Strait Islander people living in remote areas reported a higher proportion of current daily smokers (47%) than those living in non-remote areas (37%) . The overall proportion of current smokers in remote areas in 2014-2015 has only seen a minor decrease since 2002 (47% and 50% respectively).
When comparing smoking prevalence over the six years between the 2014-15 NATSISS, and the 2008 NATSISS, the highest reductions in daily smoking have been found in the younger age-groups . In 2008, the proportion of 15-24 year-olds who smoked daily was 39%, compared with 31% in 2014-2015. The proportion for the 25-34 years age-group was 53% in 2008 compared with 45% in 2014-2015.
High rates of smoking have been reported for Aboriginal and Torres Strait Islander mothers, however since 2009 the proportion of Aboriginal and Torres Strait Islander mothers who reported smoking during pregnancy has decreased from 50% in 2009 to 43% in 2016 . The proportion of smoking cessation for Aboriginal and Torres Strait Islander women during the second 20 weeks of pregnancy was 13%, compared with 26% among non-Indigenous women.
In 2014-2015, 57% of Aboriginal and Torres Strait Islander children aged 0-14 years lived in households with a daily smoker (a decline from 63% in 2008) . For those children living with a daily smoker, 13% were living in households where people smoked indoors.
In 2011, tobacco use remained the leading cause of the burden of disease and injury among Aboriginal and Torres Strait Islander people, responsible for 12% of the total burden of disease . It contributed around 40% of the disease burden to CVD, cancer and respiratory diseases. Tobacco use was also the risk factor contributing the most (23%) to the health gap between Aboriginal and Torres Strait Islander and non-Indigenous people.
Native tobacco plants (bush tobacco) grows from Queensland right across the central desert to Western Australia. These plants are known by different names including Pituri and Mingkulpa. Traditionally the leaves and stems from the tobacco plant are dried and mixed with burnt ash from specific trees. This mixture is moistened with a little saliva, then moulded into a small package known as a quid. Mixing the leaf with the ash is important, as it help the nicotine enter the body. The quid is then chewed and held in the mouth for long periods of time. It can also be placed behind the ear, which allows the nicotine to be absorbed into the body through the skin. This smokeless use of tobacco is very common across Aboriginal populations in the southern, central and western desert regions of Australia. Yet despite the long tradition of bush tobacco use, our knowledge about its impact on health is limited.
A recent narrative study  described how the use of bush tobacco is common-place in remote central Australian Aboriginal communities. Study participants were clear that ‘everyone uses it’, men, women and children. Children were said to start chewing between 5 to 7 years of age. People might hide their bush tobacco use, particularly from non-Indigenous health workers. Participants said they used bush tobacco because it tastes good and keeps you healthy. The benefits of bush tobacco described by users included:
It is possible to overdose on bush tobacco and some plants have higher levels of nicotine than others. Signs of toxicity include dizziness, drowsiness and sickness. Not being able to have bush tobacco leads to withdrawal symptoms including cravings, headaches, anxiety and grumpiness. If supplies run low, bush tobacco might be mixed with cheap commercial tobacco. Or if supplies run out, commercial tobacco might be used in place of the bush tobacco. It is also likely that some people simply prefer commercial tobacco so will regularly mix the two. Despite the recognition that commercial tobacco and bush tobacco have similar properties, users do not consider pituri to be a tobacco plant. This means that using bush tobacco is not believed to lead to the health problems associated with commercial tobacco.
The primary use of bush tobacco is for its nicotine. It is also used in some communities for other purposes including application of a wet mix to skin for treatment of:
It is often suggested that health outcomes for smokeless tobacco users are the same as those for smokers. There is some evidence to support this idea, but this information relates to commercial smokeless tobacco. We are still learning about bush tobacco, so should not assume that the outcomes for bush tobacco will be exactly the same. There are 22 different types of bush tobacco which grow wild across Australia. All are a little bit different in terms of their chemical composition, including how much nicotine they contain. Although the evidence for the health impacts of bush tobacco use are still emerging, what we do know is that:
Emerging evidence of health effects is perhaps strongest around the use of bush tobacco in pregnancy. A study of pregnant mums showed that women who chewed had higher levels of nicotine than mothers-to-be who smoked, leading to poorer health outcomes.
Even though smokeless tobacco use occurs across the world and may even be increasing, health promotion campaigns focus on tobacco that is smoked. However, the evidence we do have suggests that effective health education practices are the same, whether focused on smoked or smokeless tobacco. It is important to recognise most information about bush tobacco found in the literature comes largely from a European perspective. Recent narrative research has shown that this non-indigenous understanding of bush tobacco use is very different from that of Aboriginal peoples. Bush tobacco is not believed to be the same as commercial tobacco, so users will:
This means developing different health messages about bush tobacco. Relying on existing health messaging around commercial tobacco is unlikely to be effective as it will not be credible to bush tobacco users. Even where the emerging evidence suggests similar outcomes from bush tobacco use as for commercial tobacco use (e.g. pregnancy), health messages must respect the local knowledge system. Working closely with community to understand local beliefs and the role of bush tobacco will be important for ensuring appropriately tailored messages.
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