Why people smoke

The most important factors associated with high rates of smoking for Indigenous people appear to be linked to alcohol use, education, employment, home ownership and age [8].

Smoking is perceived by many to have a calming effect and may also be seen as an enjoyable activity over which people can retain control no matter how difficult other parts of their lives may be.

This is particularly relevant within Indigenous communities where control over other aspects of their life may be minimal. Similar factors have been found to be associated with smoking among Australians overall.

Low education, unemployment, low income, age and living in an area of socioeconomic disadvantage are all associated with higher levels of smoking in Australia [9].

Many reports suggest effective tobacco control activities should address cultural differences in smoking behaviour as well as socioeconomic disadvantage and must operate at the levels of populations, places, and environments, as well as individuals [10, 11, 12].

Factors that influence tobacco smoking

According to Quit Victoria some of the most common reasons why all people smoke are:

• emotions: feeling stressed, upset, angry, frustrated or unhappy
• pleasure: to add to the enjoyment of something or as a reward
• social pressure: to feel part of the crowd
• habit: linking smoking with other activities eg having a cup of coffee, talking on the phone
• addiction: to satisfy the craving for nicotine

Tobacco: a time for action' [13] discusses some of the major reasons why indigenous people smoke which include:

• something to do/boredom/lonliness
• keeping weight down and to stop hunger
• smoking and drinking alcohol
• smoking while gambling
• being around others who smoke
• creating personal space or time out
• general routine and habit
• addiction

In Australia, the United Kingdom, the United States, New Zealand, and elsewhere, cigarette smoking is strongly associated with socioeconomic factors [11].
People with fewer material resources, with lower status jobs, or who are unemployed are far more likely to be smokers.

An individual's risk of engaging in behaviours such as smoking may also be conditioned by social and community contexts, not just socioeconomic characteristics of the individual.

Smoking occurs more in disadvantaged areas, and giving up smoking appears to be more difficult for people living in such areas. For example, residents were more likely to smoke after consideration of factors such as individual income, education and occupation.

The effects of area-level deprivation may be related to factors in the physical and social environment such as:

• level and quality of health education
• living in an environment that is less valued, and provided fewer healthy choices
• availability of tobacco products
• level of promotion by the tobacco industry

The National Aboriginal Community Controlled Health Organisation (NACCHO), the peak organisation representing community-controlled Aboriginal health services, says smoking is not a single issue but is interwoven with other factors such as poverty, low levels of education, lack of employment opportunities, poor nutrition, disempowerment and stress [14].

Barriers to Giving Up Smoking

Smoking is such an integral part of life in many Indigenous communities that there are a range of factors which further add to the complexities around quitting. Efforts to intervene upon smoking behaviour will have limited effectiveness unless these interventions take into account the social contexts where smoking behaviour takes place.

These factors include:

The normalisation of smoking in the community - It is difficult for people to quit when the majority of their friends smoke, when they live with other smokers, and when they may not know anyone who has quit successfully. Because so many people smoke, there is no social pressure to quit.

The Culture of Sharing - It is also difficult to be a non-smoker or to quit because of the importance placed on sharing within Aboriginal culture. People share cigarettes with friends and family and it is difficult to say no in this context.

Cultural relevance of current intervention strategies - Public health interventions such as the delivery of cessation advice by health professionals and the use of nicotine replacement therapy are effective at increasing cessation rates. However, little is known about whether such interventions are appropriate and effective for and thus transferable to Aboriginal Australians [12]. There is a major lack of research on and evaluation of tobacco interventions for Indigenous Australians.

Most Indigenous ex-smokers, like other ex-smokers, quit by themselves for health reasons. Continuing smokers are more likely to quit with external support, such as Nicotine Replacement Therapy (NRT) [12].