Smoking among Indigenous Australians The Smoke Ring: Smoking among Indigenous Australians Raglan Maddox MPH, PhD Candidate | University of Canberra Chanel Webb Tobacco Action Worker | Winnunga Nimmityjah Aboriginal Health Service Perri Chapman Tobacco Action Worker | Winnunga Nimmityjah Aboriginal Health Service

Disclaimer I would like to declare that the findings I am presenting today reflect my own personal views, based on research findings and relevant evidence, and in no way reflect the views of any personal relationships, affiliations or associations that I have, which may give rise to any actual or perceived conflict of interest.

What we will cover today? Background – smoking The Smoke Ring study Preliminary findings No More Boondah Conclusions

Chronic disease risk factors - 2010 ADD NOTES HERE

Indigenous tobacco control initiative commenced March 2008 Quitline enhancement

Aboriginal and Torres Strait Islander smoking story Source: ABS Aboriginal and Torres Strait Islander Health Survey 2012-13 *Data for non-Indigenous people are for 2011-12, from the Australian Health Survey 2011-13.

Aunty Lorraine Webb Wiradjuri & Ngunnawal woman from Cowra, NSW, Australia.

Aims and objectives Gain a deeper understanding of the factors that influence smoking: is there an association between social and cultural factors and smoking? do social networks influence smoking behaviours? Evaluation The aim of the research is to contribute to the evidence-base on tobacco control interventions targeting the Indigenous Australian population in the Australian Capital Territory (ACT), with a core component investigating networks and the influence in relation to shifting tobacco use, behaviours and attitudes. The project will focus on evaluating tobacco control interventions, including the No More Boondah which has been running in the ACT since xxxx and will help inform ACT Aboriginal and Torres Strait Islander Tobacco Control strategy.

The sample Survey Key informant interviews Focus groups participants   Survey Key informant interviews Focus groups participants Participants (n) 204 10 40 (3 focus groups) Indigenous Smokers (%) 36.4% (95% CI, 27.8–44.9) 50% <50% Indigenous (%) 84% 100% Male (%) 35% 40% ≈50% Female (%) 65% 60% Mean age 35.2 years Not collected Age range 12 to 75 years ≈20 to ≈60 years 12 to ≈ 60 years Pregnant (%) 30% Median household income from all sources $67,600-$83,199 p/a ($1,300-$1,599/week) Median household size 2 people Household size range 1 – 7 people Indigenous participants: Yr 12 completed (%) 47% The aim of the research is to contribute to the evidence-base on tobacco control interventions targeting the Indigenous Australian population in the Australian Capital Territory (ACT), with a core component investigating networks and the influence in relation to shifting tobacco use, behaviours and attitudes. The project will focus on evaluating tobacco control interventions, including the No More Boondah which has been running in the ACT since xxxx and will help inform ACT Aboriginal and Torres Strait Islander Tobacco Control strategy.

Preliminary findings: overview 36.4% (95% CI, 27.8–44.9) Aboriginal and Torres Strait Islander people were smokers vs. 11.7% of all ACT residents 95% (95% CI, 91.2–98.1) of participants aged 12 and over found it ‘very easy’ or ‘fairly easy’ to get tobacco 41% of smokers could not cut back or quit 92% (95% CI, 88.3–99.5) of smokers would like to stop smoking

Preliminary analysis The model contained 10 independent variables: age; smoking status of the five closest friends and family; education - Year 12 or equivalent (highschool in the US); employment status; gender; attendance of a cultural event in the last 12 months; household income; proportion of friends that smoke; proportion of housemates that smoke; and total number of nominated friends that smoke.

Preliminary analysis: Log Regression The model was statistically significant χ2 (5, N = 49) = 28.491, p < .001, indicating that the model could distinguish between smoking and non-smoking participants. Explained between 44% (Cox and Snell R square) & 59% (Nagelkerke R squared) of the variance in smoking status, and correctly classified 82% of cases. Only two of the independent variables made a unique, statistically significant contribution to the model: completing Year 12 or equivalent proportion of housemates that smoke

Variables in the Equation Preliminary analysis: Log Regression Variables in the Equation   B S.E. Wald df Sig. Exp(B) 95% C.I. for EXP(B) Lower Upper Age 1.703 .998 2.913 1 .088 5.493 .777 38.845 Five closest friends and family smoking status 2.064 1.242 2.762 .097 7.875 .691 89.795 Year 12 or equivalent 3.068 1.020 9.051 .003 21.502 158.699 Unemployed .462 1.360 .115 .734 1.587 .110 22.822 Gender -1.911 1.224 2.436 .119 .148 .013 1.630 Attended a cultural event in the last 12 months -.471 1.145 .169 .681 .624 .066 5.888 Household income -.951 .954 .994 .319 .386 .060 2.506 Number of friends that smoke -.724 .513 1.997 .158 .485 .177 1.323 Proportion of friends that smoke -.115 1.297 .008 .930 .892 .070 11.336 Proportion of housemates that smoke 2.466 1.234 3.995 .046 11.776 1.049 132.183 Constant -1.921 1.182 2.641 .104 .146

Social Network Analysis   Total network Smokers Non-smokers Nodes 871 257 456 Number of ties 1368 181 255 Gender Males (%) 40.7 38.3 44.3 Females (%) 59.3 61.7 55.7 Age Mean 35.2 35.0 43.1 Median 34.0 31.0 43.5 Mode 24.0 29.0 42.0 Mean proportion of friends that smoke (%) 55.94 (N =161) 70.83 50.58 Mean proportion of housemates that smoke (%) 26.73 (N =179) 44.32 20.93 Mean proportion of social network that smokes (%) 39.83 (N =190) 56.95 33.44 Network diameter 31 8 Average Path Length 10.993 2.805 2.678 APL - Natural Log n 6.770 5.549 6.122 Clustering coefficient Overall graph clustering coefficient 0.022 0.057 0.008 Weighted Overall graph clustering coefficient 0.025 0.034 0.002

Total network by smoking status, gender and ties

Smoking network by gender and ties Smokers

Non-smoking network by gender and ties

Average: smoker vs non-smoker

Preliminary findings: “Social lubricant” “I think she hated me too, for not smoking, when she was [still] smoking” “smoking is seen as an everyday, acceptable or 'normalised' behaviour within our communities. Children raised in this environment will often see smoking as just another part of becoming an adult, and so the cycle continues…” “…I think it’s the influence of their parents, their grandparents, their aunts, their uncles who have smoked for years … and I’ve been smoking since I was about 11, I spose…”

What is No More Boondah? A quit smoking program developed by Winnunga that aims to: support, encourage and facilitate quit attempts educate on the harms of tobacco and addiction promote smoke free spaces and workplaces

No More Boondah Phone and group support Outreach and education Facilitates access to pharmacotherapy Transport to attend weekly group Trained tobacco workers

Why does No More Boondah work? Coordinated for and by local Aboriginal people Provides strategies for change and to support social change Clients can return to the program as often as necessary Non-judgmental and flexible environment Transport and home visits available Facilitate delivery of quit aids to clients when they are not able to access the service Evaluation and ongoing improvement

“Evidence builds confidence and confidence inspires commitment” Conclusions Locally tailored programs and local engagement to meet local community needs Strategies for change and support for social change Build on what’s been done - good work has been undertaken but more work is required “Evidence builds confidence and confidence inspires commitment”

Acknowledgements This research is funded by the ACT Government We would like to acknowledge and thank the Aboriginal and Torres Strait Islander community for their feedback, support, participation, time and willingness to contribute to the process. We would also like to acknowledge the ACT Aboriginal and Torres Strait Islander Tobacco Control Advisory Group and the following people: Dr Tom Calma AO, Chancellor & National Coordinator Tackling Indigenous Smoking Dr Ray Lovett PhD, MAE, AIATSIS & Australian National University Ms Anke van der Sterren, Centre for Excellence in Indigenous Tobacco Control Prof. Rachel Davey PHD, University of Canberra Prof. Tom Cochrane PHD, University of Canberra Ms Joan Corbett, University of Canberra This research is funded by the ACT Government